Every finding on record at St Mary's Medical Center Home Health Services, LLC

Substantial Allegation Survey Substantial Allegation: 101407 The following deficiency is based on substantial allegation 101407 completed on 11/01/23. Saint Mary’s Home Health Service 368269, is not in compliance with the requirements at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

Discharge Planning CFR(s): 484.58(a) Standard: Discharge planning. An HHA must develop and implement an effective discharge planning process. For patients who are transferred to another HHA or who are discharged to a SNF, IRF or LTCH, the HHA must assist patients and their caregivers in selecting a post-acute care provider by using and sharing data that includes, but is not limited to HHA, SNF, IRF, or LTCH data on quality measures and data on resource use measures. The HHA must ensure that the post-acute care data on quality measures and data on resource use measures is relevant and applicable to the patient's goals of care and treatment preferences. This STANDARD is not met as evidenced by: Based on record review, interview, and policy review, the agency failed to develop and implement an effective discharge process for one of three patients reviewed (Patient #1). This could affect all patients receiving services from this agency. The census was 426. Findings include: On 10/31/23 at 9:50 A.M. an interview with Staff A and Staff B revealed there was no billing completed at the agency. Further interview revealed there was no business manager physically working on-site at the agency, so billing had been completed at the home-office. The home-office is located out of state. Review of the agency's Complaint Log for the month of September of 2023 revealed Patient #1's son called in on 09/13/23 concerned about Patient #1 being listed as "active" at the agency in the system. This was blocking the patient from getting his supplies because he was not active at the agency. Further review revealed Patient #1's chart was reviewed with the son and he was informed that it was documented and reported that the patient was discharged 08/09/23 in Home Care Home Base. Further review revealed the complaint was investigated and it was confirmed that the patient was discharged with the last Outcome Assessment and Information Set (OASIS) completed on 08/09/23. An email was sent to billing to resolve the issue when this complaint was received. Staff A and Staff B revealed a Team’s chat was conducted on 09/22/23 with the Scheduling Specialist who reported that the billing issue involving Patient #1 had been resolved as of 09/22/23. Staff A stated she called the son back to inform him that the issue was resolved. On 10/31/23 at 12:26 P.M. an interview with Staff A and Staff B confirmed there was a billing delay between 08/09/23 and 09/13/23 for some unknown reason, but they both felt like the agency submitted the discharge paperwork in a timely and appropriate manner. They both stated that they did feel that someone dropped the ball, but this situation seemed like a computer glitch, or something like that, because it had never been a problem before. On 10/31/23 at 12:55 P.M. an interview with Staff A, Staff B and Staff H revealed the situation may be the company's fault, but it must have been a simple oversight that was missed in the Home Care Home Base system. Staff H stated that once the discharge OASIS was locked in the system by the agency on 08/14/23 the patient should have been able to get therapy and other treatment/supplies after 09/11/23. They could not figure out why it was delayed until 09/11/23. Further interview revealed Staff H thought this could be a mistake on the Medicare side. On 10/31/23 at 1:07 P.M. a telephone interview with Staff H revealed there was documentation supporting that Patient #1 was discharged 08/09/23 with a physician signature added on 08/11/23, the OASIS was locked on 08/14/23, but they found that another entity did not clear the discharge until 09/11/23. There was no evidence the agency or home-office determined why the issue occurred or how they would prevent it from happening in the future. This deficiency represents non-compliance investigated under Substantial Allegation 101407.

Substantial Allegation Survey Substantial Allegation 62733 and 62665 The following deficiencies are based upon substantial allegation 62733 completed on 05/17/22. No deficiencies were issued as a result of substantial allegation 62665. Saint Mary’s Home Health Service 368269, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure patients received home health agency services that are written in an individualized plan of care for three of six patient records reviewed (Patient #1, #4, and #3). The agency census was 375. Findings include: 1. Review of the complaint log revealed a complaint submitted by Patient #1. This patient had concerns because he/she did not receive his/her hospital ordered Lovenox injections after being discharged from the hospital. Review of Patient #1’s medical record revealed resumption of care comprehensive assessment was completed on 02/21/22 and Lovenox (blood thinner) injections were ordered every morning for ten days starting 02/20/22. Further review revealed the patient did not receive a skilled nursing visit until 02/23/22 and the patient did not get his/her Lovenox injections on 02/21/22 or 02/22/22 as ordered. Interview with Staff D on 05/11/22 at 10:55 AM at the time of the complaint log and medical record review confirmed the Lovenox was not given as ordered. 2. Review of the complaint log revealed a complaint submitted by Patient #4. The patient complained that he/she was discharged from the home health agency while he/she was admitted in the hospital without appropriate notification verbally or in writing. A discharge was not scheduled, and no discharge follow-up or discharge instructions was provided. Interview with Staff D on 05/11/22 at 10:55 AM revealed he/she started an investigation concerning this matter after the surveyor arrived at the agency on 05/10/22. He/she found documentation that the last skilled nursing visit was completed on 02/01/22 and the Executive Director (ED) documented the patient’s discharge date as 02/06/22 for a scheduled surgery. The ED planned to readmit the patient when he/she was discharged from the hospital after the scheduled surgical procedure. Medical record review revealed the patient’s actual discharge date was listed as 02/14/22, but the patient was not admitted to the hospital for the scheduled surgery until 03/14/22. Further interview with Staff D revealed Patient #4 did not receive skilled nursing services between 02/01/22 and 03/14/22. 3. Review of Patient #2’s medical record revealed he/she was discharged on 03/20/22, but he/she had not had any skilled nursing services since 03/08/22 when he/she was notified of pending discharge. Further record review revealed skilled nursing services was ordered for one time every week for nine weeks for medication education and diabetic foot care. There were no missed visits or care documented between 03/08/22 and 03/20/22. An interview with Staff D on 05/11/22 at 11:58 AM confirmed skilled nursing services should have been provided between 03/08/22 and 03/20/22. He/she also confirmed care was not provided as ordered, no missed visits were documented, and there was no documentation the patient’s physician was notified. This deficiency substantiates Substantial Allegation 62733.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure nursing services are provided under the supervision of a registered nurse for one of six patient records reviewed (Patient #6). The agency census was 375. Findings include: Medical record review for Patient #6 revealed skilled nursing visits three times a week. The patient had a Peripherally Inserted Central Catheter (PICC) to the right upper extremity. The patient was seen by nursing on 02/14/22 and on 02/16/22, but there was no documentation skilled nursing services were provided between 02/16/22 and 02/22/22. Further review of the medical record revealed a communication note dated 02/16/22 from Staff G, a Licensed Practical Nurse, to the Executive Director, a Registered Nurse. Staff G noted issues with the patient’s PICC line “not sticking.” Further review of the patient’s record revealed no further action was taken to ensure the patient’s PICC line was secured. The patient was not seen again by nursing until 02/22/22. An interview with Staff D on 05/11/22 at 12:30 PM confirmed the findings and stated the Registered Nurse should have followed-up with the patient before 02/22/22. This deficiency substantiates Substantial Allegation 62733.

Substantial Allegation Survey Substantial Allegation 61758 The following deficiency is based upon substantial allegation 61758 completed on 02/24/22. Saint Mary's Home Health Service 368269, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies. .

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on interview, record review, and policy review, the agency failed to ensure the Administrator was responsible for the day to day operations of the agency for one of three patients reviewed (Patient #1). This had the potential to affect all patients receiving home health services from the agency. The census was 428. Findings include: Review of the policy titled, Patient Discharge/Transfer Process , last revised 01/01/22 revealed if a patient is discharged because the agency can no longer meet the needs of the patient, the agency will assist the patient/patient representative in choosing an alternate provider that can meet the patient needs. Documentation will support that the patient was informed that the agency can no longer meet his/her needs and alternatives were provided to the patient. Further policy review revealed patients are to be notified as soon as possible prior to discharge as outlined in the agency notice of non-coverage policy, and in the expedited determination and reconsideration for discharge policy. The agency will also provide the patient and legal representative (if any) with contact information and numbers for other community resources or providers and evidence will be documented in the medical record. Review of Patient #1's medical record revealed she was admitted to the agency on 12/17/20. Review of the physician ordered plan of care for the certification period dated 12/12/21 through 02/09/22 revealed orders for skilled nursing one time a week for nine weeks. The skilled nurse was to provide instructions/reinforcement of nephrostomy care including appliance and stoma care. Cleanse skin around stoma with alcohol pad. Apply telfa pad to insertion site then cover with tegaderm daily and as needed. Further review revealed the patient signed a discharge notification form on 01/19/22 but added she did not agree with the discharge and added she felt the discharge could be because her daughter stopped working full time at the agency as a registered nurse (RN). Further review of the nursing notes revealed friends, neighbors, and other relatives were listed as care providers. A physician did sign on 01/14/22 for the patient to be discharged on 01/23/22. No follow-up instructions, or contact information was noted on the discharge form. On 02/23/22 at 10:43 A.M. a telephone interview with Staff C confirmed he/she was a Licensed Practical Nurse (LPN) and he/she did provide Skilled Nursing (SN) services for the patient on a regular basis while working for the agency. Further interview revealed he/she knew nothing about a pending discharge for the patient until “it popped up on my electronic calendar to discharge”. Further interview revealed Staff C was informed the patient would be discharged the next week because the patient did not require skilled nursing services any longer. Further interview with Staff C revealed he/she did not feel the patient could can take care of herself without assistance from someone. On 02/23/22 at 11:13 A.M. a telephone interview with Staff D revealed he/she had provided evaluations and skilled nursing services for the patient. Further interview revealed the patient did need help because the patient could not reach her back to care of her medical needs. Further interview revealed Staff D felt the patient was “dropped” without appropriate discharge instructions, or other options for care. “We dropped the ball on this one”. Further interview revealed Staff D felt it was a miscommunication between field staff, office staff, and “everyone involved”. On 02/23/22/at 11:20 A.M. a telephone interview with Staff E (who is also the patient's family member) revealed he/she was a RN. He/she did not assist the patient with care needs because he/she and the patient were not on speaking terms. Further interview with Staff E revealed he/she did feel like the patient was “dropped” without other treatment options being offered after discharge. On 02/23/22 at 12:00 P.M. an interview with Staff A and Staff F revealed that they both had looked at the patient's record and both felt the patient's family member, Staff E, was going to provide the patient's care. Further interview with Staff A revealed he/she knew the family dynamics between the patient and Staff E were not the best, but he/she did not know how bad the family dynamics were when the patient was discharged. This deficiency substantiates Substantial Allegation 61758.