Every finding on record at Vsl Vetter Home Health Care of Central Nebr. LLC

Brookestone Home Health and Hospice is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies.

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: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure the patient and/or patient representative was notified of the extent to which payment for Home Health Agency services will be covered and/or the amount the patient may have to pay prior to care being initiated for 6 of 10 patients (Patient 5, 6, 7, 8, 9, and 10). The census was 76. Findings are: A. Review of the agency policy and procedure Bill of Rights and Resposibilities [sic]- Patient Copy, no date indicated, revealed the agency was to fully inform the patient, prior to receiving care, the extent to which the home health services will be paid by Medicare or other sources, and the extent to which payment will be required by the patient. B. Review of Patient 5's clinical record revealed: 1. The start of care was 5/5/23. 2. Payment method, amount paid the payor, and/or the amount the patient was expected to pay for the home health services, was incomplete on the Fee Agreement/Consent form (a form signed by the patient which includes an explanation of the services expected to be provided to the patient, the amount the payor source will pay, and the amount the patient is expected to pay for the home health services). There was no documentation to indicate the patient was provided this information prior to the initiation of care. C. Review of Patient 6's clinical record revealed: 1. The start of care date was 3/9/23. 2. Payment method, amount paid the payor, and/or the amount the patient was expected to pay for the home health services, was incomplete on the Fee Agreement/Consent form. There was no documentation to indicate the patient was provided this information prior to the initiation of care. D. Review of Patient 7's clinical record revealed: 1. The start of care date was 5/22/23. 2. Payment method, amount paid the payor, and/or the amount the patient was expected to pay for the home health services, was not include on the Fee Agreement/Consent form. There was no documentation to indicate the patient was provided this information prior to the initiation of care. E. Review of Patient 8's clinical record revealed: 1. The start of care date was 5/22/23. 2. Payment method, amount paid the payor, and/or the amount the patient was expected to pay for the home health services, was incomplete on the Fee Agreement/Consent form. There was no documentation to indicate the patient was provided this information prior to the initiation of care. F. Review of Patient 9's clinical record revealed: 1. The start of care date was 12/13/22. 2. Payment method, amount paid the payor, and/or the amount the patient was expected to pay for the home health services, was incomplete on the Fee Agreement/Consent form. There was no documentation to indicate the patient was provided this information prior to the initiation of care. G. Review of Patient 10's clinical record revealed: 1. The start of care date was 4/18/23. 2. Payment method, amount paid the payor, and/or the amount the patient was expected to pay for the home health services, was incomplete on the Fee Agreement/Consent form. There was no documentation to indicate the patient was provided this information prior to the initiation of care. H. During an interview on 7/12/23 at 08:45 AM, the Administrator confirmed payment method, amount paid the payor, and/or the amount the patient was expected to pay for the home health services, was incomplete on the Fee Agreement/Consent form. There was no documentation to indicate the patient was provided this information prior to the initiation of care for Patient 5, 6, 7, 8, 9, and 10.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start 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 complete a comprehensive assessment of the patient's physical therapy (PT), occupational therapy (OT), and/or speech therapy (ST) needs no later than 5 days of the start of care for 2 of 8 patients (Patient 4 and Patient 9) who had orders for PT, OT and/or ST services. The total sample size was 10. The census was 76. Findings are: A. Review of the agency policy and procedure titled, Submission of Patient Documentation, revised 11/10/17, revealed the agency was to complete an Outcome and Assessment Information Set (OASIS) within 5 days of the start of care. The policy does not indicate the need to complete the comprehensive assessment by all disciplines involved in the plan of care no later than 5 days of the patient's start of care. B. Review of Patient 4's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 5/23/23 through 7/21/23, included orders for PT, OT, and ST to evaluate and treat. 2. The patient's start of care was 5/23/23. 3. A ST Evaluation was completed on 5/30/23 (7 days after the start of care). 4. There was no documentation in the clinical record to indicate the patient/caregiver requested a delay in the comprehensive assessment by the ST. C. Review of Patient 9's clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 12/13/22 through 2/10/23, included orders for PT and OT to evaluate and treat. 2. The patient's start of care was 12/13/22. 3. A PT evaluation was completed on 12/19/23 (6 days after the start of care). 4. An OT evaluation was completed on 12/21/23 (8 days after the start of care). 5. There was no documentation in the clinical record to indicate the patient/caregiver requested a delay in the comprehensive assessment by the PT or OT. D. During an interview on 7/12/23 at 08:45 AM, the Administrator and the Quality Assurance Performance Improvement Coordinator (QAPI) confirmed the start of care by PT, OT, and or ST for Patient 4 and Patient 9 were not completed no later than 5 days of the start of care date. They also confirmed it is the agency policy to complete assessments by all disciplines within 5 days of the patients start of care.

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 information about the patients progress towards agency and patient identified outcomes and goals on the revised/updated plan of care for 4 of 4 patients (Patient 1, 2, 5, and 6) who had a revised/updated plan of care. The total sample size was 10. The census was 76. Findings are: A. Review of the policy and procedure titled Physicians Progress Reports/60 Day Summary, revised 9/18/17 revealed: 1. The agency was to update and/or revised the plan of care no less than every 60 days. 2. The revised plan of care was to include information concerning the patient's progress toward the measurable outcomes and goals identified by the Home Health agency. B. Review of Patient 1's clinical records revealed: 1. The start of care was 4/25/23. 2. The revised updated Home Health Certification and Plan of Care for the certification period of 6/24/23 through 8/22/23 did not include information concerning the patient's progress toward the measurable outcomes and goals identified by the Home Health agency and the patient. C. Review of Patient 2's clinical record revealed: 1. The start of care was 9/13/22. 2. The revised updated Home Health Certification and Plan of Care for the certification period of 3/12/23 through 5/10/23, 5/11/23 through 7/09/23, and 7/10/23 through 9/7/23 (record review periods) did not include information concerning the patient's progress toward the measurable outcomes and goals identified by the Home Health agency and the patient. D. Review of Patient 5's clinical record revealed: 1. The start of care was 5/5/23. 2. The revised updated Home Health Certification and Plan of Care for the certification period of 7/4/23 through 9/1/23 did not include information concerning the patient's progress toward the measurable outcomes and goals identified by the Home Health agency and the patient. E. Review of Patient 6's clinical record revealed: 1. The start of care was 3/9/23. 2. The revised updated Home Health Certification and Plan of Care for the certification period of 5/8/23 through 7/6/23 did not include information concerning the patient's progress toward the measurable outcomes and goals identified by the Home Health agency and the patient. F. During an interview on 7/11/23 at 2:50 PM, the Administrator confirmed the agency failed to include information concerning the patient's progress toward the measurable outcomes and goals identified by the Home Health agency and the patient on the revised/updated plan of care for Patient 1, 2, 5, and 6.