Every finding on record at Starx Inc

• Purpose of visit: Recertification/Relicensure/Complaint • Entrance date: 11/25/2024 • Census: L&CHHS 4 LHHS22 PAS 8 • Intake#: 521385 & 530659 Abbreviations: Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Licensed and Certified Home Health Services (L&CHHS) Outcome and Assessment Information Set (OASIS) Internet Quality Improvement and Evaluation System (IQIES an internet-based system that includes survey and certification functions) Centers for Medicare & Medicaid Services (CMS) Quality Assessment Performance Improvement Plan (QAPI) The facility is in compliance with no deficiencies cited.

• Purpose of visit: Recertification/Relicensure/Complaint • Entrance date: 11/25/2024 • Census: L&CHHS 4 LHHS22 PAS 8 • Intake#: 521385 & 530659 Abbreviations: Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Licensed and Certified Home Health Services (L&CHHS) Outcome and Assessment Information Set (OASIS) Internet Quality Improvement and Evaluation System (IQIES an internet-based system that includes survey and certification functions) Centers for Medicare & Medicaid Services (CMS) Quality Assessment Performance Improvement Plan (QAPI)

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 the completed Outcome and Assessment Information Set (OASIS) assessment for 1 (patient #4) of 4 records reviewed to the state agency within 30 days of completing the OASIS assessment of the patient. Failure of the agency to transmit OASIS data within the required time frame prevented the agency’s patient data from being made available to Centers for Medicare & Medicaid Services (CMS) for analysis to identify agency performance levels in the provision of patient care. Findings: The surveyor reviewed the OASIS transmission report for the agency on the Internet Quality Improvement and Evaluation System (IQIES an internet-based system that includes survey and certification functions) portal on 11/25/2024, as part of the preparation for the survey. In an interview with the Office Manager on 11/25/2024 at approximately 10:10 AM, the surveyor requested the Centers for Medicare & Medicaid Services (CMS) OASIS Agency Final Validation report for the last 12 months and asked who was responsible for the Oasis transmissions. The Office Manager said, “I’m responsible for the Oasis transmissions.” The surveyor reviewed the OASIS Agency Final Validation report provided by the Office Manager on 11/26/2024. The agency Oasis Agency Final Validation report documented: 1) Patient #4 was admitted to the agency effective 08/06/2024 and remained an active patient as of 11/26/2024. The report documented the date of the Admission Assessment as entered by the agency at OASIS assessment item M0090 was 08/06/2024. The report documented the submission date of the admission was 11/24/2024. The report documented the following error message: “Record submitted late: The submission date is more than 30 days after M0090 (Oasis coding used to determine the last date that information used to complete the assessment completed) on this new record.” An interview was conducted with the Office Manager and Alternate Administrator/Director of Nursing on 11/26/2024 at 2:50 PM. The surveyor reviewed the Centers for Medicare & Medicaid Services (CMS) OASIS Agency Final Validation report provided the agency with the Office Manager and Alternate Administrator/Director of Nursing. The surveyor reviewed the findings of the late transmission of the assessment for patient # 1. The surveyor asked why the Oasis were transmitted late by the agency. The Office Manager stated, “I got distracted. It was an oversight.”

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 interview and record review, the agency failed to develop, implement, and evaluate performance improvement projects for 3 of 3 (2021, 2022, and 2023) years reviewed. This failure could have resulted in the agency failing to identify and address areas of the agency’s program for which performance could be improved. The findings included: On 11/27/24 reviewed of the QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN (QAPI) documentation regarding the agency’s Quality Assessment Performance Improvement Plan (QAPI) Program included no documentation to indicate the agency had developed, implemented, or evaluated a performance improvement project for the years 2021, 2022, and 2023. During an interview with the Alternate Administrator on 11/27/2024 at approximately 11:55 AM the surveyor presented the above findings. The surveyor asked who was responsible for the agency QAPI program and committee meetings. The Alternate Administrator stated, "Me and the Administrator. The performance improvement projects were an oversight on our part.” Review of agency policy, dated 050124, quoted in part, "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PROGRAM QAPI.5, read in part” .... E. Performance Improvement Projects 1. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency’s services and operations…QAPI documents will be kept confidential and will be made available to State Home Health licensing agency staff on request..."

Purpose: Recertification Survey Entrance Date: 11/15/2021 at 11:41 a.m. with the Administrator Census: Licensed and Certified - 13 patients Exit Date: 11/18/2021 at 2:21 p.m. with the Administrator and the Director of Nursing The agency was given the opportunity to provide additional information during the survey. The preliminary findings were discussed. Written instructions were given for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies and the time frame that the agency would receive the Statement of Deficiencies. Deficiency cited. The agency was in compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to have an individualized emergency plan in 3 (#1, #2, #3) of 3 patients that received a home visit from the surveyor. The failure placed the patients at risk for negative outcomes. Findings Include: Patient #1: A review of the clinical record revealed a Plan of Care dated 8/11/2021 to 10/9/2021. The Plan of Care indicated that Patient #1 started on the agency's services on 6/12/2021. The Plan of Care listed Legally Blind, Vision Deficit, Dyspnea (shortness of breath) with minimal exertion, and ambulation as functional limitations. The clinical record contained a Recertification Comprehensive Assessment conducted by Registered Nurse C on 8/6/2021. Registered Nurse C identified that Patient #1 was on Hemodialysis. The clinical record did not contain an individualized emergency plan. A home visit was conducted on 11/17/2021 at 2:00 p.m. with Patient #1. The surveyor reviewed the home folder given to Patient #1 by the agency. Patient #1 informed the surveyor that no papers were missing and Patient #1 had not been given a written individualized emergency plan. The home folder contained a booklet titled, "{Agency name} Life Delivered." The booklet contained an untitled form that listed where the Disaster Classification, physician name, alternate physician, pharmacy name, emergency contact person, Hospital preferences, Special Needs (equipment, Medications, Transportation Issues, etc.), and evacuation site information could be documented. The form was blank. Patient #2: A review of the clinical record revealed a Plan of Care dated 10/4/2021 to 12/2/2021. The Plan of Care indicated that Patient #2 started on the agency's services on 10/4/2021. The Plan of Care listed Ambulation, Bladder Incontinence, Dyspnea with Moderated exertion, Endurance, and Vision Deficit as functional limitations. The clinical record did not contain an individualized emergency plan. A home visit was conducted on 11/17/2021 at 9:49 a.m. with Patient # and Patient #2's caregiver. The surveyor reviewed the home folder given to Patient #2 by the agency. Patient #2's caregiver informed the surveyor that no papers were missing and Patient #2 had not been given a written individualized emergency plan. The home folder contained a booklet titled, "{Agency name} Life Delivered." The booklet contained an untitled form that listed where the Disaster Classification, physician name, alternate physician, pharmacy name, emergency contact person, Hospital preferences, Special Needs (equipment, Medications, Transportation Issues, etc.), and evacuation site information could be documented. The form was blank. Patient #3: A review of the clinical record revealed a Plan of Care dated 10/14/2021 to 12/12/2021. The Plan of Care indicated that Patient #3 started on the agency's services on 10/14/2021. The Plan of Care listed Ambulation, Bladder Incontinence, Dyspnea with minimal exertion, Endurance, Vision, Deficit, and Speech/Communication Deficit as functional limitations. The clinical record did not contain an individualized emergency plan. A home visit was conducted on 11/17/2021 at 10:55 a.m. with Patient #3 and Patient #3's caregiver. The surveyor reviewed the home folder given to Patient #3 by the agency. Patient #3's caregiver informed the surveyor that no papers were missing and Patient #3 had not been given a written individualized emergency plan. The home folder contained a booklet titled, "{Agency name} Life Delivered." The booklet contained an untitled form that listed where the Disaster Classification, physician name, alternate physician, pharmacy name, emergency contact person, Hospital preferences, Special Needs (equipment, Medications, Transportation Issues, etc.), and evacuation site information could be documented. The form was blank. During an interview on 11/17/2021 at approximately 12:12 p.m. with the Director of Nursing/Alternate Administrator and the Office Manager, the surveyor discussed the individualized emergency plans and asked questions. The Office Manager informed the surveyor that the individualized emergency plans should be in the documents scanned into the record. The Office Manager assisted the surveyor to navigate the electronic records and was unable to find the individualized emergency plans. The surveyor was shown a form from the booklet that is given to patients on admission. This form was the same form that was the untitled form that listed where the Disaster Classification, physician name, alternate physician, pharmacy name, emergency contact person, Hospital preferences, Special Needs (equipment, Medications, Transportation Issues, etc.), and evacuation site information could be documented. The surveyor discussed that the forms were blank in the patients' home folders. The Alternate Administrator informed the surveyor that the form was to be filled out by the nurses and did not know why the forms had been left blank. The agency was given the opportunity to find the original individualized emergency plans. By exit from the agency on 11/18/2021, the agency was not able to present the original individualized emergency plans to the surveyor.

Purpose: Recertification survey Entrance Date: 11/15/2021 at 11:41 a.m. with the Administrator Census: Licensed and Certified -13 patients Exit Date: 11/18/2021 at 2:21 p.m. with the Administrator and the Director of Nursing The agency was given the opportunity to provide additional information during the survey. The preliminary findings were discussed. Written instructions were given for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies and the time frame that the agency would receive the Statement of Deficiencies. Deficiency cited The agency was in compliance with 42 CFR Part 484, Conditions of Participation for Home Health Agencies.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to individualize the Plan of Care to include patient specific interventions in 1 (#1) of 1 patient record reviewed where the patient was on dialysis. The Plan of Care did not include that the patient was on dialysis, that the patient had an arteriovenous shunt, assessment of the arteriovenous shunt, and safety measures regarding the arteriovenous shunt. The failure placed the patient at risk for complications to the arteriovenous shunt. Findings Include: Patient #1: Record of the clinical record revealed a Plan of Care dated 8/11/2021 and 10/9/2021. The Plan of Care indicated that Patient #1 started on the agency's services on 6/12/2021. The Plan of Care listed Sepsis, Heart Failure, Diabetes with Chronic Kidney Disease, Hypertensive Heart and Chronic Kidney with Heart Failure and Stage 1-4 Chronic Kidney, and Chronic Kidney Disease Stage 4 as diagnoses. The record contained documentation of a Recertification Comprehensive Assessment conducted on 8/6/2021 by Registered Nurse C. Registered Nurse C documented that Patient #1 was on dialysis and had dialysis treatments on Mondays, Wednesdays, and Fridays. Registered Nurse C did not document the location of the dialysis access, type of dialysis access, or assessment of the site. The record contained documentation of a skilled nurse visit conducted on 8/13/2021 by Licensed Vocational Nurse D. Licensed Vocational Nurse D documented in the genitourinary portion of the assessment, "Dialysis AV fistula (shunt)." Licensed Vocational Nurse D did not document the site of the shunt or assessment of the shunt. Licensed Vocational Nurse D documented that blood pressure readings were obtain on the left and right arm. Blood Pressure readings: left165/70 and 158/78 on the right. A home visit to interview Patient #1 was conducted on 11/17/2021 at 2:00 p.m. During home visit, Patient #1 showed the surveyor that the shunt was in the left forearm. Patient #1 informed the surveyor that the nurse did not obtain blood pressure readings on the left arm, "Because she can't." Patient #1 informed the surveyor that the nurse felt the shunt and listened to the shunt with a stethoscope during visits. During an interview on 11/17/2021 at approximately 12:12 p.m. with the Director of Nursing, the surveyor discussed the dialysis status and asked questions. The Director of Nursing informed the surveyor that the shunt should have been on the Plan of Care and the safety parameters should have been on the Plan of Care. The Director of Nursing informed the surveyor that the Director of Nursing did not know why it was not included in the Plan of Care. A Plan of Care dated 10/10/2021 to 12/8/2021 did not include that Patient #1 was on dialysis, had an arteriovenous shunt in the left forearm, assessment, or safety measures. The agency utilized the 'Handbook of Home Health Nursing Procedures' by Robyn Rice for nursing procedure policies. Chapter 12 of the handbook contained the Arteriovenous Fistula and Shunt Care policies on pages 311-314. The policy read in part:..."Preserving Patency of the Arteriovenous fistula. Procedure...2. Assess patency of the AV fistula or shunt in the following way: a. Place the stethoscope over the suture line and auscultate for a bruit (if patent, the fistula will sound like a full bounding pulse) b. Gently palpate the shunt or fistula. (Palpation should elicit a bruit)..Nursing Considerations. Do not take blood pressures, perform venipunctures, or give injections on an arm with an AV fistula or shunt...Documentation guidelines. Document the following on the visit report....Patency of the AV fistula and shunt, including auscultatory findings when assessing the fistula or shunt....Update the patient care plan."