Healthy Living at Home, LLC

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure a comprehensive assessment including the OASIS (Outcome and Assessment Information Set- a patient-specific, a standardized data set that measures quality and outcomes required for Medicare and Medicaid patients in home health care) was completed at discharge for 1 of 7 sampled patients (Patient 7). This failure had the potential for the agency to not identify if Patient 7 had met the care planned goals at discharge. A review of Patient 7’s Plan of Care (POC) indicated, she was admitted to the agency on 5/22/24 with multiple diagnoses that included Laceration without foreign body, right lower leg. The POC included physician orders to receive skilled nursing (SN), physical therapy (PT) and occupational therapy visits and be discharged when goals were met. There was no documented evidence that a comprehensive assessment including an OASIS assessment was completed for Patient 7 upon discharge. During a concurrent telephone interview and record review on 10/22/24 at 4:00 p.m., with the Vice President of Accreditation, Regulations and Education (VPA), the VPA verified Patient 7 was discharged from the agency according to the coordination note dated 9/20/24. The VPA verified, the comprehensive assessment and OASIS discharge assessment was not done for Patient 7 because it was not generated when the agency discharged the patient. The VPA stated, an OASIS discharge assessment should have been completed for Patient 7. A review of the agency policy titled, “REASSESSMENTS/RECERTIFICATION”, dated, March2024, indicated, “…OASIS assessments for recertification… and discharge will be completed within the mandated time frames. 4.Each patient will be reassessed using a comprehensive OASIS assessment tool for the review and revision of the plan of care when: D. The patient is discharged…””

“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 interview and record review, the agency failed to complete a discharge summary for one of 7 sampled patients (Patient 7) upon discharge. This failure had the potential to result in lack of coordination of care after Patient 7 was discharged from the agency. A review of Patient 7’s Plan of Care (POC) indicated, she was admitted to the agency on 5/22/24 with multiple diagnoses that included Laceration without foreign body, right lower leg. The POC included physician orders to receive skilled nursing (SN), physical therapy (PT) and occupational therapy visits and be discharged when goals were met. There was no documented evidence that Patient 7’s discharge summary was completed and sent to her provider. During a concurrent telephone interview and record review on 10/22/24 at 4:00 p.m., with the Vice President of Accreditation, Regulations and Education (VPA), the VPA verified Patient 7 was discharged from the agency according to the coordination note dated 9/20/24. The VPA verified Patient 7 had no discharge summary in her clinical records. The VPA stated, when a patient was discharged, a discharge summary should have been completed and sent to the provider. A review of the agency policy titled, “DISCHARGE SUMMARY”, updated, 6/14/23, indicated, “…1. The discharging clinician will complete a discharge summary at the time of discharge…” A review of the agency policy titled, “DISCHARGE CRITERIA AND PROCESS”, approved March 2024, indicated, “…8. A discharge summary will be completed for all discharged patients. A copy may be mailed to the primary physician…11. All discharge paperwork will be due in the office within 72 hours of the discharge date. This will include the discharge order, discharge summary, plan of care, medication profile, and OASIS…””