Every finding on record at Stellar Home Health Care, Inc

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 05/24/24. Standard level deficiencies cited. Abbreviations: Pt. /Pts. = Patient/Patients PT = Physical Therapist SOC = Start of Care SN = Skilled 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 the review of the Error Summary report and Staff interview, it was determined in 157 of 271 reports submitted for the last 12 months, and 30 of 88 reports for the year to date, the Agency failed to submit timely reports, resulting in a warning. Finding include: 1. The Error Summary reports were reviewed on 05/21/24 at 11:30 AM. The report for the last 12 months, 05/01/23 -04/30/24, included error # -3330 for 157 of 271 submissions, 57.93% of the reports submitted were more than 30 days after the M0090. The Year to date Summary report, 01/01/24 -05/23/24, also included error # -3330 for 30 of 88 submissions, 34.09% of the reports submitted were more than 30 days after the M0090. 2. During the interview with the Assistant Administrator, on 05/23/24 at 1:00 PM, it was stated the Nurses were submitting OASIS notes to the office, late, which he needed for the OASIS submissions. 3. The findings were confirmed during the interview with the Administrator on 05/23/24 between 11:30 AM and 2:00 PM.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical records review and staff interviews it was determined that 3 of 7 (Pts # 1, 3 and 5) clinical records reviewed clinicians failed to prepare clinical notes. 2. Pt. #3 was admitted to Home Health Services on 02/15/24 with the diagnosis of Chronic Obstructive Pulmonary Disease with acute Exacerbation. The clinical record was reviewed on 05/21/24. The clinical record lacked the SN visit notes for 04/18/24 thru 05/16/22. A home visit was conducted on 05/22/24 with the SN (Employee #3). During the home visit interview with Pt.#3 on 05/22/24, 4:00 PM, it was confirmed by Pt.#3 that the SN conducted weekly visits. During the interview with Employee #3, it was confirmed all the weekly visits were conducted. 3. Pt. #5 was admitted to the Home Health Services on 04/22/24 with the diagnoses of Pressure Ulcer to Left Buttock Stage 2 and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 05/14/24. The clinical record lacked the SN visit notes for 05/13/24 thru 05/20/22. On 05/22/24 at 11:30 am, during the interview with the Clinical Manager, it was stated the visits were conducted. 4. The findings were confirmed during the interview with the Clinical Manager on 05/22/24 between 11:30 AM and 12:30 PM. Findings include: 1. Patient # 1 was admitted to Home Health services on 03/14/24 with Diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 05/22/23 and contained a Recertification POC for 05/13/24 to 07/11/24 that required PT to evaluate for services. A home visit was conducted for Pt#1 on 05/22/24 at 9:30AM with the DON. During an interview with patient and patient caregiver, the patient caregiver stated that PT has been visiting patient 2 times a week since the SOC date. The clinical record lacked PT visit notes week 1 and week 2 of recertification period beginning 05/13/24.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on the clinical records review and staff interview it was determined that 3 of 7 clinical records reviewed (Pts. #4, 5 and 7) contained incomplete documents. 4. Patient # 7 was admitted to Home Health Services on 10/06/23 with Diagnosis of Multiple Myeloma not having achieved remission. The clinical record was reviewed on 05/21/24. The clinical record contained a document titled: Advance Beneficiary Notice of Noncoverage (ABN) signed and dated by patient on 10/06/23. The signed document was not fully completed, the document lacked what services are not covered. 5. During interviews with the Administrator and Director of Nursing on 05/22 and 05/23/24 between 11:30 AM and 1:00 PM. The finding of clinical records containing incomplete documentation were confirmed. Findings include: 1. Pt. #4 was admitted to Home Health Services on 03/14/24 with the diagnosis of Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 05/21/24. The clinical record included an incomplete form titled “Advance Beneficiary Notice of Non-coverage”, signed and dated by the patient on 03/14/24. The signed document was incomplete. The document lacked what services are not covered. 2. Pt. #5 was admitted to Home Health Services on 04/22/24 with the diagnoses of Pressure Ulcer to Left Buttock Stage 2 and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 05/14/24. The record included an incomplete form titled “Advance Beneficiary Notice of Non-coverage”, signed and dated by the patient on 04/22/24. The signed document was incomplete. The document lacked what services are not covered.

Recertification survey completed. Standard level deficiencies cited. A Focused infection control survey was conducted on 5/20/2021. The Facility was in compliance with the requirements for Infection Control for COVID-19. Abbreviations: AM= Morning PM= Afternoon Pt./Pts. = Patient/Patients SOC= Start of Care

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, and staff interview, it was determined the Agency failed to ensure Patients are advised of the extent of their financial liability for care, and/or services and changes on services/items before care is initiated. This was found in 4 of 7 (Pts. #1, 2, 5 and 6) clinical records reviewed. Findings include: 1. The clinical records of the Patients listed below were reviewed on 5/18/21 at 9:45 AM to 5/19/21 at 4:00 PM. All of the records contained a form, which was signed by the Pt at the SOC titled: "Home Health Change of Care Notice" included the sections: "Items/Services and Reason for change." The section lacked documentation indicating the change in the item/services and the reason for change. All of the records also contained a form, which was signed by the Pt. at the SOC titled: "Advance Beneficiary Notice of Non-Coverage (ABN)" with the section titled: "G. Options: Check only one box..." The section, "Option 1." if checked, indicates, "I want D. (blank) listed above" but lacked documentation on what the items were, the reason Medicare may not pay and estimated cost. Pt. #1 SOC: 5/03/21 Pt. #2 SOC: 4/23/21 Pt. #5 SOC: 1/27/21 Pt. #6 SOC: 6/26/20 2. The above findings were confirmed during an interview with the Administrator and Director of Nursing on 5/19/21 at 3:30 PM.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: . A. Based on clinical record review and staff interview, the Agency failed to ensure documentation of forms were complete and accurate. This was found in 3 of 5 (Pts.# 2, 5, and 1) active clinical records reviewed. Findings include: 1. Pt. # 2. SOC 4/23/21. Primary Diagnosis: Acute and Chronic Respiratory Failure with Hypercapnia. The clinical record was reviewed on 5/18/21 at 11:00 AM. The record included a form, "Beneficiary Elected Transfer," signed by Pt. #2 and dated 4/23/21. The form lacked documentation of the previous agency's name, phone number and address. The record also included a form, "Change of Personal Physician" which was signed by Pt. #2 on 4/23/21. The form lacked the name of the Physician being released and the Physician being authorized to be the Pt's attending and the start date. 2. Pt. # 5. SOC 1/27/21. Primary Diagnosis: Chronic Obstructive Pulmonary Disease. The clinical record was reviewed on 5/18/21 at 4:00 PM. The record included a form, "Beneficiary Elected Transfer," signed by Pt. #5 and dated 1/27/21. The form lacked documentation of the previous agency's name, phone number and address. The record also included a form, "Change of Personal Physician" which was signed by Pt. #5 on 1/27/21. The form lacked the name of the Physician being released and the Physician being authorized to be the Pt's attending and the start date. . 3. Pt. # 1. SOC 1/3/21. Primary Diagnosis: Cerebral Palsy unspecified. The clinical record was reviewed on 5/18/21 at 1:00 PM. The record included the following forms: "Beneficiary Elected Transfer," signed by Pt. on 5/3/21 upon admission. The form did not include the previous agency's name, phone number and address. "Change of Personal Physician," signed by Pt. on 5/3/21 upon admission. The form did not include the name of the released attending Physician and the new Physician who was being authorized to be the Pt's attending upon admission. 4. During interviews with the Director of Nursing (DON) and Administrator on 5/19/21 at 3:00 PM and 9/20/21 at 10:30 AM with DON, both confirmed the above documents were incomplete and/or inaccurate.