Every finding on record at Venus Home Health, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 12/06/24. Standard level deficiencies cited.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of Agency’s Emergency Preparedness Plan, In-services training records, personnel file and staff interview, it was determined that in 7 of 11 Employees (Employees # 1, 2, 3, 8, 9, 10 and 11) reviewed, the Agency failed to conduct staff training related to Agency’s Emergency Preparedness Plan. Findings include: 1. The Agency’s Emergency Preparedness Plan, In-services training records and personnel files were reviewed on 12/04/24 and 12/05/24. The In-services training records and personnel files lacked documentation of staff training related to Emergency Preparedness for the following employees: Employee # 1 (PT / Date of Hire 09/23/24) Employee # 2 (RN / Date of Hire 07/16/24) Employee # 3 (LPN / Date of Hire 09/23/24) Employee # 8 (HHA / Date of Hire 11/03/06) Employee # 9 (HHA / Date of Hire 12/03/18) Employee # 10 (HHA / Date of Hire 05/22/17) Employee # 11 (HHA / Date of Hire 07/01/24) 2. During an interview with the Administrator on 12/05/24 at 12:00 PM, the Administrator confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 12/06/24. Standard level deficiencies cited. Abbreviations: # = number % = percent AM = morning > = greater than BP = blood pressure LPN = Licensed Practical Nurse SN = Skilled Nurse RN = Registered Nurse PT = Physical Therapy HHA = Home Health Aide POC / PsOC = Plan of care / Plans of care SOC = Start of care PM = afternoon/evening Pt./ Pts. = Patient/Patients OASIS = Outcome and Assessment Information Set

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 review of the Error Summary report and staff interview, it was determined that in of 304 of 583 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 12/01/23 to 11/30/24 (12 months), was reviewed on 12/05/24. The report included a warning for Error # -3330. The Error included 304 (52.14 %) of 583 assessments that were submitted late. 2. During an interview with the Administrator, Clinical Manager, Case Manager and Office Manager on 12/05/24 at 2:30 PM, the Administratuve team stated that the timeframe for submission of OASIS is within 30 days after completion. During the same interview, the Administrative team confirmed the above findings.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on review of the Agency’s Pt. admission folder, observation and interview during home visits, clinical record review, and staff interviews, it was determined that in 4 of 7 (Pts. # 2, 3, 5, and 7) clinical records reviewed, the Agency failed to ensure the Pt./representative was informed in writing of the services to be provided and the frequency of visits. Findings include: 1. The Pt. admission folder was reviewed on 12/02/24 at 10:00 AM. The folder included the “Consent for Home Health Services and Agreement” form that included a section titled "Services Provided/Frequency of Visit", requiring the SN to complete during the SOC visit and document the services to be provided and visit frequencies. 2. The following clinical records were reviewed on 12/03/24 to 12/04/24: Pt. #2. SOC 10/03/24. Pt. received SN, PT and HHA services. Pt. #3. SOC 03/08/24. Pt. received SN and PT services. Pt. #5. SOC 03/11/24. Pt. received SN and HHA services. Pt. #7. SOC 03/07/24. Pt. received SN services. The clinical records included the “Consent for Home Health Services and Agreement” form signed by the Pt./representative. The consent forms lacked documentation of the service(s) to be provided and visit frequencies. 3. Home visits were conducted on the following Pts. on 12/02/24: Pt. #2. SOC 10/03/24. Pt. #3. SOC 03/08/24. During the home visits of Pts. #2 and 3, the Pt. admission folders were observed and lacked documentation indicating the Pt./representative was notified of the discipline(s) to provide service, and frequency of visits in writing. 4. During staff interviews with the Administrator, Clinical Manager and Case Manager, on 12/04/24 at 1:30 PM and 12/05/24 at 9:30 AM; the Administrative team confirmed the above findings.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on review of clinical records, and staff interview, it was determined in 2 of 7 (Pts. #2,and 3) clinical records reviewed, the Agency failed to ensure the initial assessment was done within 48 hours upon receipt of a referral. Findings include: 1. Pt. #2 was admitted to home health services on 10/03/24 with the diagnosis of Type 2 Diabetes Mellitus with Hyperglycemia. The record included a NP(Nurse Practitioner) referral for home health services dated 09/06/24. The record included the initial SOC assessment, dated 10/03/24. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 12/05/24, the record lacked documentation the Agency initiated service within the required time frame. 2. Pt. #3 was admitted to home health services on 03/08/24 with the diagnosis of Unspecified Dementia, Unspecified Severity, without Behavioral, Psychotic, Mood, and Anxiety Disturbance. The record included a Physician referral for home health services dated 03/05/24. The record included the initial SOC assessment, dated 03/08/24. The record lacked documentation of an inpatient facility stay or physician ordered SOC date. As of 12/05/24, the record lacked documentation the Agency initiated service within the required time frame. 3. During staff interviews with the Administrator, Clinical Manager and Case Manager, on 12/04/24 at 1:30 PM, the Administrative team confirmed the above findings.

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 clinical records review and staff interview, it was determined that in 2 of 7 (Pts. # 5 and 7) clinical records reviewed, the patient care was not provided as ordered in the POC. Findings include: 1. Pt. #5 was admitted to home health services on 03/11/24 with the diagnosis of Pressure Ulcer of Right Heel stage 2 and Pressure Ulcer of Left Heel, Unstageable. The clinical record was reviewed on 12/04/24. The POC effective 11/06/24 to 01/04/25, required to notify Physician of vital sign parameters out of range: “….Diastolic Blood Pressure:….less than (There was no Physician notification of blood pressure falling outside of range, as ordered in the POC. 2. Pt. #7 was admitted to home health services on 03/07/24 with the diagnoses of Other Disorder of Bone Density and Structure, Atherosclerotic Heart disease of Native Coronary Artery without Angina Pectoris and Presence of Cardiac Pacemaker. The clinical record was reviewed on 12/03/24. The POC effective 05/06/24 to 07/04/24, required to notify Physician of vital sign parameters out of range: “….Diastolic Blood Pressure:….less than (There was no Physician notification of diastolic blood pressure falling outside of range, as ordered in the POC. 3. During an interview with the Administrator, Clinical Manager, Case Manager and Office Manager on 12/05/24 at 9:30 AM, the Administrative team confirmed the above findings.

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 clinical records review and staff interview, it was determined that in 2 of 7 (Pts. #6 and 7) clinical records reviewed, the Agency failed to ensure the POC contained patient specific interventions indicated for a pertinent Diagnosis. Findings include: 1. Pt. #6 was admitted to home health services on 05/28/24 with the diagnosis of Pulmonary Fibrosis. The clinical record was reviewed on 12/03/24. The POC effective 07/27/24 to 09/24/24, included orders for discipline and treatment: “Notify Physician…. Blood sugar, Fasting….Blood Sugar, Random…” The POC included a blood sugar assessment intervention that was not indicated for Pt. #6’s diagnosis. 2. Pt. #7 was admitted to home health services on 03/07/24 with the diagnoses of Other Disorder of Bone Density and Structure, Atherosclerotic Heart disease of Native Coronary Artery without Angina Pectoris and Presence of Cardiac Pacemaker. The clinical record was reviewed on 12/03/24. The POC effective 05/06/24 to 07/04/24, included orders for discipline and treatment: “Notify Physician…. Blood sugar, Fasting….Blood Sugar, Random…” The POC included a blood sugar assessment intervention that was not indicated for Pt. #7’s diagnosis. 3. During an interview with the Administrator, Clinical Manager, Case Manager and Office Manager on 12/05/24 at 9:30 AM, the Administrator stated that all patients will have a standing order for blood sugar. During the same interview, the Administrative team confirmed the above findings.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined in 1 of 2 (Pt. #5) clinical records reviewed, wherein the Pt. received Home Health Aide services, the Agency failed to ensure the RN conduct Home Health Aide supervision every 14 days. Findings include: 1. Pt. #5 was admitted to home health services on 03/11/24 with the diagnoses of Pressure Ulcer of Right Heel stage 2 and Pressure Ulcer of Left Heel, unstageable. The clinical record was reviewed on 12/04/24. The record contained the Home Health Aide visit notes dated 10/24/24, 10/28/24, 10/31/24, 11/06/24 and 11/08/24. As of 12/04/24, the record lacked documentation of a Home Health Aide supervision by the RN from 10/24/24 to 11/08/24. 2. During interviews with the Administrator, Clinical Manager, Case Manager and Office Manager on 12/05/24 at 9:30 AM, the Administrator stated that the RN conducts Home Health Aide supervision every 14 days. During the same interview, the Administrative team confirmed the above findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interview, it was determined that in 2 of 2 (Pts. #6 and 7) closed clinical records reviewed, the Agency failed to ensure that the Physician was sent a copy of the discharge summary within 5 days of discharge. Findings include: 1. Pt. #6 was admitted to home health services on 05/28/24 with the diagnosis of Pulmonary Fibrosis. The clinical record was reviewed on 12/03/24. The discharge summary dated 09/20/24, indicated Pt. #6 was discharged from the Agency. The record lacked documentation that the discharge summary was sent to the Physician within 5 days of discharge. 2. Pt. #7 was admitted to home health services on 03/07/24 with the diagnoses of Other Disorder of Bone Density and Structure, Atherosclerotic Heart disease of Native Coronary Artery without Angina Pectoris and Presence of Cardiac Pacemaker. The clinical record was reviewed on 12/03/24. The discharge summary dated 07/02/24, indicated Pt. #7 was discharged from the Agency. The record lacked documentation that the discharge summary was sent to the Physician within 5 days of discharge. 3. During an interview with the Administrator, Clinical Manager, Case Manager and Office Manager on 12/05/24 at 9:30 AM, the Administrative team confirmed the above findings.