Every finding on record at The University of Kansas Health System Home Health - Olathe LLC

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (4F371-HI) at the above-named Home Health Agency (HHA) from 08/15/2022 to 08/18/2022 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (4F371-HI) conducted at the above-named Home Health Agency (HHA) from 08/15/2022 to 08/18/2022 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on interviews, record review, and facility policy review, the agency failed to ensure a comprehensive assessment, including an Outcome and Assessment Information Set (OASIS), was completed at the time of discharge for one (Patient 2) of 17 patients whose assessments were reviewed. This failure resulted in delayed collection of OASIS information for Patient 2. Findings Include: Review of an agency policy titled, “Home Health & [and] Hospice Timeliness of Documentation,” revised 08/2022, showed that the discharge OASIS must be synchronized to the office database when the discharge process is completed. Review of the, “Home Health Certification and Plan of Care (POC),” dated 05/23/2022, showed that the agency admitted Patient 2 on 05/14/2022, with diagnoses that included cellulitis (an infection) of the left lower limb, kidney failure, and heart failure. Additionally, the document showed that the agency provided physical therapy and nursing services to Patient 2. Further review showed that the agency discharged the patient from physical therapy services on 06/07/2022 and from nursing services on 06/08/2022. Review of a “Discharge Summary,” dated 06/08/2022, showed that Patient 2 was discharged from the agency on 06/08/2022 because Patient 2 had met all service goals. Review of Patient 2’s, “Skilled Nursing Visit,” record, dated 06/08/2022, showed no evidence that a discharge OASIS assessment was completed on the patient's discharge date. Review of an untitled note dated 08/08/2022 in Patient 2’s clinical record showed that Patient 2’s discharge OASIS assessment was completed on 06/08/2022 and that corrections to the document were made in collaboration with the clinician who completed Patient 2’s discharge assessment. During a concurrent record review and interview conducted on 08/18/2022 at 10:10 AM with the agency's Quality Supervisor (QS), an electronic communication showed the agency had not completed a discharge OASIS assessment for Patient 2 on 06/08/2022. The QS stated a traveling nurse (nurse who worked for an independent agency and provided temporary services to the home health agency) had completed Patient 2’s discharge visit on 06/08/2022 and had completed an incorrect form, which did not include the discharge OASIS assessment. The QS further stated the agency was unable to contact the traveling nurse when the agency discovered the error and that Patient 2’s OASIS discharge assessment was completed on 08/08/2022. The QS indicated the agency used clinical information from the traveling nurse’s discharge visit documentation and a previous physical therapy assessment note to complete the discharge. The agency did not provide a copy of the electronic communication. During an interview on 08/08/2022 at 11:45 AM, the Executive Director (ED) stated the agency's expectation was that staff were to complete a patient’s discharge OASIS assessment within 48 hours of the patient’s discharge from the agency.

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 interview and record reviews, it was determined the agency failed to include pertinent diagnoses on the plans of care (POCs) for 4 (Patients 1, 7, 12, and 15) of 17 sampled patients whose plans of care were reviewed. This failure had the potential to cause Patients 1, 7, 12, and 15 to not receive staff education and services related to management of their health issues. 3. Review of Patient 12’s POC dated 06/29/2022 showed the agency admitted Patient 12 on 06/29/2022, with diagnoses that included type 2 diabetes with foot ulcer, non-pressure chronic ulcer of other part of left foot with fat layer exposed, and low back pain. Further review showed that Patient 12 was taking fluoxetine 20 milligram (mg) oral capsule (a medication used to treat depression and other mood disorders) once daily in the morning and fluoxetine 40 mg oral capsule once daily in the evening. The POC did not include any diagnoses related to depression or mood disorders. 4. Review of Patient 15’s POC dated 05/04/2022 showed the agency admitted Patient 15 on 05/04/2022, with diagnoses that included after care following joint replacement surgery and stage 3 chronic kidney disease. Further review showed that Patient 12 was taking fluoxetine 20 mg oral capsule once daily. The POC did not include any diagnoses related to depression or mood disorders. During an interview on 08/17/2022 at 10:33 AM, the Executive Director (ED) stated once the agency received a referral, a clinician would go out to conduct a comprehensive assessment. This assessment included reviewing the patient's medications. The ED stated the agency's clinicians would ask about each medication and the reason the patient was taking the prescribed medication during this process. On 08/17/2022 at 10:59 AM, the surveyor requested a copy of the agency's policy on diagnosis review during patients' comprehensive assessments. No policy was provided during the survey. Based on interview and record reviews, it was determined the agency failed to include pertinent diagnoses on the plans of care (POCs) for 4 (Patients 1, 7, 12, and 15) of 17 sampled patients whose plans of care were reviewed. This failure had the potential to cause Patients 1, 7, 12, and 15 to not receive staff education and services related to management of their health issues. Findings Include: 1. Review of Patient 1’s, “Home Health Care Certification and Plan of Care (POC),” dated 08/12/2022, showed that the agency admitted Patient 1 on 06/05/2022, with diagnoses that included aftercare after surgery, malignant neoplasm of the rectum (a cancerous tumor in the rectum), and care of an ileostomy (a surgical opening in the abdomen that allows digested food to move out of the intestines and empty into an external bag attached to the abdomen). Further review showed that Patient 1 was taking sertraline (a medication used to treat depression and other mood disorders) one time per day. The plan of care did not include any diagnoses related to depression or mood disorders. 2. Review of Patient 7’s POC, dated 08/16/2022, showed the agency admitted Patient 7 on 08/11/2022, with diagnoses that included high blood pressure with heart failure, type 2 diabetes mellitus (high levels of sugar in the blood), and respiratory failure. Further review showed that Patient 7 was taking levothyroxine (a medication used to treat thyroid issues) one time per day. The plan of care did not include any diagnoses related to thyroid issues.