Every finding on record at The Evangelical Lutheran Good Samaritan Society

Evangelical Lutheran GSS Home Care of Central Nebraska is in compliance with the requirement of CFR 484.102 Condition of Participation for Home Health Agencies.

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, policy and procedure review, and staff interview, the agency failed to electronically transmit each completed Outcome Assessment Information Set (OASIS, a patient specific standardized assessment, used in Medicare home health care, to plan care, determine reimbursement, and measure quality) assessment to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of completing the OASIS assessment and failed to follow the agency's policy and procedure to ensure the OASIS assessment transmissions were timely. The census was 57. Findings are: A. Review of the Home Health Agency Error Summary by Agency Report, from Internet Quality Improvement & Evaluation System (iQIES, a cloud base application used by CMS to evaluate the quality of care for Medicare and Medicaid beneficiaries, and help manage patient and provider information) for 1/1/23 through 12/31/23, revealed 30 out of 1174 OASIS assessments were transmitted to the State Agency or the CMS OASIS contractor more than 30 days after completing the OASIS assessment. B. Review of the agency’s policy and procedure titled OASIS, Home Health-Enterprise, date reviewed/revised 7/19/23, revealed, the agency will electronically transmit OASIS assessment data to the State Agency or CMS OASIS contractor within 30 days of the OASIS assessment completion date. C. During an interview on 6/26/24 at 4:50 PM, the Administrator confirmed agency staff failed to follow the agency's policy and procedure for OASIS assessment transmissions within 30 days of completing the OASIS assessment.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to include on the revised/updated plan of care, the patient’s progress towards the measurable outcomes and goals identified by the home health agency and the patient, for 6 of 6 patients (Patient 2, 3, 4, 6, 7, and 8) who had a revised/updated plan of care. The total sample size was 8. The census was 57. Findings are: A. Review of the agency’s policy and procedure titled Care Planning and Care Coordination, Home Health and Therapy-Enterprise, date reviewed/revised 5/2/2024, revealed: 1. The individualized plan of care will identify patient specific, measurable outcomes and goals, including interventions. 2. The goals and outcomes should include the patient’s involvement and coordinated among all disciplines. 3. The plan of care must be reviewed and revised no less frequently than once every 60 days. B. Review of clinical records revealed: 1. Patient 2’s Home Health Certification and Plan of Care (POC), for the certification periods of 4/3/24 through 6/1/24 and 6/2/24 through 7/31/24, did not include the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. 2. Patient 3’s POC, for the certification period of 5/14/24 through 7/12/24, did not include the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. 3. Patient 4’s POC, for the certification periods of 2/29/24 through 4/28/24 and 4/29/24 through 6/27/24, did not include the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. 4. Patient 6’s POC, for the certification period of 4/26/22 through 6/24/22, did not include the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. 5. Patient 7’s POC, for the certification periods of 3/3/24 through 5/1/24 and 5/2/24 through 6/30/24, did not include the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. 6. Patient 8’s POC, for the certification periods of 3/4/24 through 5/2/24 and 5/3/24 through 7/1/24, did not include the patient’s progress towards the measurable outcomes and goals as identified by the home health agency and the patient. C. During an interview on 6/26/24 at 4:50 PM, the Administrator confirmed the progress towards the measurable outcomes and goals as identified by the home health agency and the patient were not included on the revised/updated POC for Patients 2, 3, 4, 6, 7, and 8.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on record review, policy and procedure review, observation of the provision of care, and staff interview, the agency failed to ensure 4 of 4 staff (Staff B, C, D, and I), observed during the provision of care for 4 of 4 patients (Patient 1, 2, 3, and 8, respectively), performed proper hand hygiene and bag technique according to the agency's policies and procedures. The total sample size was 8. The census was 57. Findings are: A. Review of the agency’s policy and procedure titled Bag Technique, HBS- Enterprise, date reviewed/revised 6/14/24, revealed: 1. Hand hygiene is to be performed prior to removing supplies from the bag. 2. Equipment is to be cleaned prior to returning to the bag. 3. Bag is to be securely zipped after clean items are returned to the bag. 4. Nothing classified as dirty should be placed inside the bag. 5. A bag is used by agency staff to carry equipment and supplies into a patient's home. The bag should be placed on a barrier to maintain a clean surface and prevent contamination of the bag's outer surface. B. Review of the agency’s policy and procedure titled Hand Hygiene-Enterprise, date reviewed/revised 3/29/22, revealed, hand hygiene can be either washing hands with soap and water or using a waterless alcohol-based hand sanitizer. C. Review of clinical records revealed: 1. Patient 1’s Home Health Certification and Plan of Care (POC), for the certification period of 6/15/24 through 8/13/24, included orders for Physical Therapy (PT), to evaluate and treat. The PT Plan of Care included orders for PT 1 time a week for 2 weeks, to increase strength, balance, and activity tolerance to decrease risk of falls and mobility disability. 2. Patient 2’s POC, for the certification period of 6/2/24 through 7/31/24, included orders for Home Health Aide 1 time a week to assist with activities of daily living, showering, and obtain vital signs. 3. Patient 3’s POC, for the certification period of 5/14/24 through 7/12/24, included orders for Skilled Nursing (SN) 1 time a week to assess and instruct the patient with intravenous site cares, ostomy care and management, set up medications in a pill planner set, assess wounds, and assess indwelling urinary catheter (a tube inserted through the urethra into the bladder, connected to a drainage bag, to collect and drain urine) and change monthly. 4. Patient 8’s POC, for the certification period of 5/3/24 through 7/1/24, included orders for SN every 2 weeks for Home Health Aide supervision and 1 time a month to assess safety, fall prevention, and medication review. D. The observation of the provision of care, for Patient 1 on 6/25/24 at 8:30 AM, revealed Staff B failed to keep the bag securely zipped upon entrance into and exit from the home. E. The observation of the provision of care, for Patient 2 on 6/25/24 at 1:00 PM, revealed Staff C placed clean equipment on the dirty area of the barrier prior to returning the equipment into the bag. F. The observation of the provision of care, for Patient 3 on 6/25/24 at 11:30 AM, revealed Staff D placed clean equipment on the dirty area of the barrier prior to returning the equipment into the bag. G. The observation of the provision of care, for Patient 8 on 6/27/24 at 10:45 AM, revealed Staff I failed to perform hand hygiene prior to entering the bag to obtain COVID wipes. H. During an interview on 7/1/24 at 2:45 PM, the Administrator confirmed Staff B, C, D, and I, failed to follow the agency’s policy and procedure for hand hygiene and bag technique during the provision of care for Patient 1, 2, 3, and 8, respectively.