Every finding on record at Wellmark, Inc.

A Medicare Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 05/13/25-05/15/25 resulted in a finding of the following deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on interview and review of the facility's Emergency Preparedness Plan (EPP), the Agency failed to maintain a current list of names and contact information in an "Emergency Preparedness Communication Plan" that included all facility staff members, patient physicians and providers, and all entities providing services to the agency under arrangement. The deficient practice had the potential to affect the 101 patients receiving care from the agency. Findings include: Review of the facility's EPP on 05/15/25 at 1:30 PM with the Director of Nursing (DON) revealed the EPP did not contain an effective communication plan, including accurate identification of all the agency's staff and their contact information. In an interview on 05/15/25 at 1:45 PM, the DON confirmed many of the staff names and contact numbers on the agency’s communication plan were not accurate. The DON confirmed the contact information had not been updated since the emergency plan was last reviewed by the agency’s governing board on 11/22/23.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on interview and review of the facility's Emergency Preparedness Plan (EPP), the Agency failed to maintain a current method of alternate communication with staff and outside agencies in the event the usual methods of communication were not available during a disaster. The deficient practice had the potential to affect the 101 patients receiving care from the agency. Findings include: Review of the facility's EPP on 05/15/25 at 1:30 PM with the Director of Nursing (DON) revealed the EPP, most recently reviewed by the agency’s Governing Board on 11/22/23, indicated a HAM (amateur radio) radio system would be used for communication with staff and outside resources in the event the usual methods of communication were not available during a disaster. Observations, conducted at the agency’s office on 05/15/25 at 1:15 PM of available resources to be used during a disaster, revealed nothing to indicate the agency had access to a HAM radio. In an interview on 05/15/25 at 1:45 PM, the DON confirmed the agency did not have access to a HAM radio. The DON stated this resource had not yet been put into place. The DON stated all resources listed in the agency’s EPP were expected to be available during a potential disaster, including the HAM radio indicated in the current EPP.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on Emergency Preparedness Plan (EPP) review and interview, the Agency failed to participate in a community-wide functional exercise at least every two years. This deficient practice had the potential to affect all 101 patients receiving services from the agency. Findings include: Review of the agency's "Emergency Preparedness Disaster Plan," dated 11/22/23, failed to reveal documentation to show the agency participated in a community-wide functional exercise every two years. Review of the EPP revealed no current policy to indicate when and how the facility was to perform biannual EPP functional exercises. During an interview on 05/15/25 at 1:45 PM, the Director of Nursing (DON) confirmed the agency had not participated in a community-wide functional exercise at least every two years. The DON was unable to provide documentation to show that any exercise had ever been performed.

A Medicare Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of Nevada Department of Health and Human Services. The survey conducted from 05/13/25 through 05/15/25 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484 Subparts A through C with the following standard-level deficiencies listed below. There was one complaint investigated. Complaint 106653 could not be substantiated. The investigation included: Observation of the agency practices and care provided in sampled patient’s home. Interviews were conducted with patients and their family members, and agency staff. Record Review of seven sampled patients.

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 and interview, the Home Health Agency (HHA) failed to ensure the timely submission of OASIS (Outcome and Assessment Information Set) to IQIES (Internet Quality and Improvement and Evaluation System). The deficient practice had the potential to affect all 101 patients receiving services from the HHA who require evaluation and care. Findings include: The facility's OASIS submission data for calendar year 2024 was reviewed and revealed nine out of a total of 49 assessments were coded as being transmitted to IQIES more than 30 days late during that time period. This resulted in an error code of -3330 (late submission) for 18.37% of all assessments submitted in the 2024 calendar year. During an interview on 05/15/25 at 1:45 PM, the Director of Nursing (DON) confirmed some OASIS submissions were likely transmitted late due to nursing staff not locking their assessments of patients on time.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the Home Health Agency (HHA) failed to ensure the agency completed a criminal background check for one employee out of a total of 10 sampled employee records (Physical Therapy Assistant (PTA1) upon hire and prior to the employee working directly with patients. This deficient practice had the potential to affect all 101 patients receiving services from the HHA. Findings include: The agency's "Personnel Records Policy," revised 02/2024 read, ". . . Personnel files will be established and maintained for all staff . . . The personnel record or personnel information for an employee will include, but not be limited to, the following: criminal history check, if required by law; and National Sex Offender check; and OIG's (Officer of Inspector General's) Exclusion list." Review of PTA 1's employee record revealed PTA 1 was hired by the agency on 05/10/24. The record indicated PTA 1's initial background check was not completed until 05/23/24 (almost two weeks after the PTA 1 began working with the agency and after PTA 1 began seeing patients independently in their homes to provide services). During an interview on 05/15/25 at 1:30 PM, the Director of Nursing (DON) confirmed the agency was not able to provide evidence to show a criminal background check had been completed for PTA 1 after their hire and prior to PTA 1 working directly with patients. The DON confirmed PTA 1 was currently employed with the facility and was providing direct care and treatment for patients. The DON stated the expectation was that criminal background checks would be completed for all staff prior to staff working directly with patients.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record review, and interview, the Home Health Agency (HHA) failed to ensure a Registered Nurse (RN) conducted a medication reconciliation during homecare visits for one of five sampled patients (Patient (P) 1) reviewed for medication reconciliation. This deficient practice had the potential to affect all 101 patients receiving services from the HHA. Findings include: Observation during a homecare visit performed by Physical Therapist (PT) 1 on 05/13/25 at 4:00 PM revealed that P1's "Medication List," found in P1's Electronic Medical Record (EMR), did not accurately reflect the medications being administered to the patient in the group home. Medications found in P1's home and reflected as being given in the patient's home Medication Administration Record (MAR) included Vitamin B12 2000 Micrograms (mcg) by mouth daily, Vitamin C 1000 Milligrams (mg) by mouth daily, and Vitamin D3 4000 International Units (IUs) by mouth daily. The Agency's "Patient Medication Profile," found in the EMR and dated 05/13/25, revealed orders that indicated P1 was to receive Vitamin B12 1000 mcg by mouth daily, Vitamin C 500 mg by mouth daily, and Vitamin D3 2000 IUs by mouth daily. The medications administered in the home did not match the orders in place in the Agency's EMR. During an interview on 05/13/24 at 4:30 PM, P1's group home caregiver confirmed P1's current prescribed medications and confirmed P1 was being given the medications indicated on the group home MAR routinely per physician's order. During an interview on 05/15/25 at 1:30 PM, the Director of Nursing (DON) confirmed P1 was receiving weekly skilled nursing visits and indicated that medications were expected to be reconciled by the nurse at every visit. The DON stated the expectation was that the medications being administered to residents in their homes should match the Agency's medication order set.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, record review, policy review, and interview, the Home Health Agency (HHA) failed to ensure that a physician’s order for routine central intravenous (IV) catheter line dressing changes to be performed by skilled nursing staff was in place and current for one Patient (P) P7 of a total of 10 sampled patients reviewed during the survey. This deficient practice had the potential to affect all 101 patients receiving services from the HHA who have physician’s orders in place for care. Findings include: Review of the agency's "Physician’s Plan of Care – CMS 485 and Physician/Practitioners Orders Policy," revised 02/2024 revealed, "Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment of immediate and long-range needs and resources. Each plan of care must be signed and dated by the physician/allowed practitioner . . . The individualized plan of care must specify the care and services necessary to meet patient-specific needs as identified in the comprehensive assessment." Review of P7's medical record revealed no current orders were in place for P7’s central IV line dressing changes. Review of the patient’s record revealed the central IV catheter dressing was being changed by skilled nursing staff with each weekly nursing visit. During an interview on 05/15/25 at 1:30 PM, the Director of Nursing (DON) confirmed there was no current order in place in P7’s record for the central IV catheter dressing changes. The DON stated the expectation was an order would be in place for all nursing care provided for patients, including P7’s central IV catheter dressing changes.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the Home Health Agency (HHA) failed to ensure physician’s orders/plan of care were reviewed and signed timely at least every 60 days by the Patient’s physician for three of 10 sampled patients (Patients (P) P1, P4, and P6) reviewed during the survey. This deficient practice had the potential to affect all 101 patients receiving services from the HHA. Findings include: Review of the agency's Physician’s Plan of Care – CMS 485 and Physician/Practitioners Orders Policy," revised 02/2024, revealed, ". . . Skilled nursing and other home health services will be in accordance with a Plan of Care based on the patient’s diagnosis and assessment of immediate and long-range needs and resources. Each plan of care must be signed and dated by the physician/allowed practitioner . . ." 1. Review of P1's medical record revealed the patient’s CMS 485 (Home Health Certification and Plan of Care) was most recently initiated for continuation of home health services for the 60-day period of 03/18/25 through 05/16/25. The document indicated P1 was to receive skilled nursing and physical therapy services throughout the certification period. Review of the record revealed P1 was receiving services according to the plan of care (CMS 485), however there was no evidence to show the document had been reviewed and signed by the patient’s physician to validate the patient’s need for services and establish orders for the patient to receive the services. 2. Review of P4's medical record revealed the patient’s CMS 485 was most recently initiated for continuation of home health services for the 60-day period of 04/04/25 through 06/02/25. The document indicated P4 was to receive skilled nursing and physical therapy services throughout the certification period. Review of the record revealed P4 was receiving services according to the plan of care (CMS 485), however there was no evidence to show the document had been reviewed and signed by the patient’s physician to validate the patient’s need for services and establish orders for the patient to receive the services. 3. Review of P6's medical record revealed the patient’s CMS 485 was most recently initiated for continuation of home health services for the 60-day period of 04/02/25 through 05/31/25. The document indicated P6 was to receive skilled nursing, physical therapy, and occupational therapy services throughout the certification period. Review of the record revealed P6 received services according to the plan of care (CMS 485), however there was no evidence to show the document had been reviewed and signed by the patient’s physician to validate the patient’s need for services and establish orders for the patient to receive the services. During an interview on 05/15/25 at 1:30 PM, the Director of Nursing (DON) confirmed the CMS 485 form had not been signed by P1, P4, or P6’s physician. The DON confirmed the CMS 485 was expected to be signed by each patient’s physician within 30 days of the initiation or continuation of services for each 60-day certification period. The DON stated physicians were often difficult to reach to ensure review and implementation of valid and current orders for patient services.

A Medicare Recertification survey including a review of the Emergency Preparedness Program was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 03/29/2021 through 03/31/2021 resulted in no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

A Medicare Recertification Survey and Focused Infection Control Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. The survey conducted from 03/29/2021 through 03/31/2021 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

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 record review and interview the home health agency failed to complete an initial assessment within 48 hours of the referral, or within 48 hours of the patient's return home, or based on the physician ordered start of care date. This deficient practice affected two of 13 patients (Patient (P)3 and P11). This failure had the potential for a patient to experience an adverse event due to not receiving needed care in a timely manner. Findings include: Review of the medical record under the Physician's Orders Tab for P3 revealed a physician signed order form dated 10/07/2019 for PT (physical therapy) and nursing for gait instability and hypertension. The patient was not in the hospital at the time of the referral. Review of the Start of Care OASIS (Outcome and Assessment Information Set) revealed a Start of Care Date of 10/19/2019. Review of the medical record failed to identify documentation of why the initial assessment was not completed within 48 hours of the physician referral. Review of the medical record under the Physician's Orders Tab for P11 revealed a signed physician ordered dated 06/09/2020 for a registered nurse (RN) for ADL's (activities of daily living), medication management, and wound care. Review of the Start of Care OASIS revealed a Start of Care Date of 06/15/2020. Review of the medical record failed to identify documentation of why the initial assessment was not completed within 48 hours of the physician referral. During an interview on 03/31/2021 at 10:15 AM, the Administrator seemed unaware of the requirement to admit a patient within 48 hours of a physician referral or return home following a hospital inpatient stay or on the date indicated in a physician order. The Administrator stated the agency could not admit " ... until we get all the information..." referring to medical history and physical, insurance information, and hospital discharge summary if applicable. The Administrator was unable to provide a policy that addressed a time frame for an initial assessment following a physician referral.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on policy review, record review and interview, the agency failed to ensure coordination of care, and integration of services as evidenced by blank "Case Conference" forms for 2 (Patient (P5), P6) of 13 patients. Findings include: A review of the Outcome and Assessment Information Set (OASIS), "Home Health Patient Tracking Sheet" for Patient (P)5 identified a start of care date of 03/09/2021 with a certification period of 03/09/2021 to 05/07/2021. The diagnoses included: hypertension (primary), fracture on left femur from a fall, diabetes, chronic kidney disease and chronic obstructive pulmonary disease. The "Home Health Certification and Plan of Care" signed by the Registered Nurse (RN) on 03/12/2021 identified orders for Skilled Nursing (SN) two times a week for one week; once a week for eight weeks; and Physical Therapy (PT) frequency and duration: evaluate and treatment. The Physician's Order on 03/09/2021 for patient skilled nursing interventions included: management, medication reconciliation, patient/family education, individualized patient emergency care plan, fall precautions/fall prevention program, universal/standard precautions, infection control measures, and proper nutrition/hydration. Physical Therapist was to evaluate P5, as "the patient is on limited weight bearing on left lower extremity." The "Case Conference" form for P5's start of care on 03/09/2021 for the certification period of 03/09/2021-05/07/2021 was blank. [Case Conference form is a means of communication to team members, to assure the coordination and integration of all services and interventions provided to the patient.] The OASIS "Home Health Patient Tracking Sheet" for P6 identified a start of care on 02/23/2021 for a certification period of 02/23/2021 to 04/23/2021. Diagnosis included osteomyelitis, left ankle, and foot (primary), diabetes, pressure ulcer, stage 4. The "Plan of Care" for P6 identified professional services of Skilled Nursing two times a day for four days then once daily, to start on 02/27/2021 X 26 days and reassess. The physician order for treatment as noted on the 02/03/2021 "Plan of Care" included the following: "For comprehensive skilled nursing assessment, evaluation/observation of all body systems, with focus on musculoskeletal, integumentary, endocrine, cardiovascular and renal system, mental/emotional status, nutrition/hydration status, review medications, diet, home safety, provide health teachings, and evaluate compliance and response to treatment regimen." The "Case Conference" form for a start of care on 02/23/2021 and the certification period of 02/23/2021-04/23/2021 was blank. A review of the policy "Assessment and Reassessment Guidelines," number 9.5.1, revised 10/2017, section 4 "Communication" stated, "Pertinent assessment and reassessment data will be communicated to team members, patient and the patient's physician by case conference, telephone, in person or in writing." Procedures on the policy "Coordination of Patient Care," number 9.13.1, revised 10/2017, included the following: "The agency must: Assure communication with all physicians involved in the plan of care. Integrate orders from all physicians involved in the plan of care to assure the coordination of all services and interventions provided to the patient. Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any) and caregiver(s) as appropriate, in the coordination of care activities." During an interview on 03/31/2021 at 11:35 AM, regarding patient case conferences for P5 and P6 at the Start of Care, the Administrator stated, "This (Case Conference Form) should have been done already. The Nurse will tell us what the patient's need is. It is a communication for all to see what the needs of the patient are [skilled nursing, physical therapy, occupational therapy, social work, certified nursing assistant]. It should be done on admission. It is a required (form), they missed it, they were to complete the form."

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency (HHA) failed to monitor, manage, and maintain the equipment used to access the web-based medical record system. This had the potential to result in unauthorized access to patient information for all patients receiving care from the HHA. Findings include: During an interview on 03/29/2021 at 9:30 AM, the Administrator stated the HHA used a web-based medical record program for documentation. The Administrator confirmed the HHA did not own or provide the electronic equipment staff used to access the electronic medical record (EMR) program. The Administrator stated staff used their personal desktop computers, laptops, cell phones, and any other electronic device capable of accessing the internet. Surveyors received a log-in and password to access patient records in the EMR system. During review of patient information in the EMR it was observed that the patient assessments, plan of care, visit notes, and patient personal information including address, date of birth, social security number, and insurance information, could be saved to the computer desktop and be accessed when not logged into the web-based patient medical documentation program. During an interview on 03/30/2021 at 11:30 AM, following a home visit observation, Registered Nurse (RN)1 would complete documentation of the patient assessment in the EMR after returning home later in the day. RN1 would access the patients EMR on a personal desktop computer located in the RN's home. RN1 stated when a patient had a wound, a picture would be taken on the RN's personal cell phone to be uploaded into the EMR. During an interview on 03/31/2021 at 10:15 AM, the Administrator stated all staff received training on confidentiality of patient information, HIPAA (Health Insurance Portability and Accountability Act), and safeguarding the password for the web-based patient information documentation system. The Administrator acknowledged that he would not know if a staff person saved patient information or photos to their personal electronic equipment. The Administrator also stated he would not know if a staff person lost their personal electronic equipment that might contain patient information or if staff had equipment stolen unless they told him.