Human Touch Home Health Care Agency Delta

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to have an emergency preparedness plan that included a facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings Include: 1. On 11/20/24 a review of the agency’s emergency preparedness plan revealed the plan did not include a facility-based and community-based risk assessment, utilizing an all-hazards approach. a. The agency failed to have an emergency preparedness plan that included a facility-based and community based risk assessment. During an interview 11/20/24, at 12:20 p.m., The administrator stated the agency did not have documentation, nor a plan including a facility- based and community based risk assessment that utilizes an all-hazards approach.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to maintain an emergency preparedness training and testing program based on a Centers for Medicare and Medicaid (CMS) standards based emergency preparedness plan, risk assessment, policies, procedures, and the communication plan, in accordance with Section 483.73(d). Findings include: 1.On 11/20/24 a review of the personnel files revealed no evidence to conclude personnel had been trained or demonstrated knowledge of CMS standards based emergency procedures within the regulated time frame. a. The agency failed to maintain emergency preparedness training to demonstrate staff knowledge of emergency procedures. During an interview on 11/20/24, at 12:20 p.m., the administrator stated the training program had not been maintained to train each staff member providing services within the past two years. They continued to state personnel did not complete ongoing training that trained and tested on a CMS standards based facility emergency preparedness plan, risk assessment, policies, procedures, and communication plan. They concluded by stating there was no documentation available regarding ongoing training and testing on a CMS standards based emergency preparedness plan, risk assessment, policies, procedures, and communication plan.”

“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 agency failed to ensure each beneficiary who received Medicare, a Medicare advantage plan, and/or Medicaid’s Outcome and Assessment Information Set (OASIS) was electronically encoded and transmitted to the Centers for Medicare and Medicaid Services (CMS) in 1 of 1 discharged patient, who required an OASIS to be transmitted, record reviewed (Patient #6); and based on interview and record review of CMS OASIS Error Detail report, the agency failed to electronically transmit current and accurate data regarding each beneficiary with respect to which information was required to be transmitted within 30 days of completing the assessment of the beneficiary for 3 current patients (Patients #1, #2 and #4) whose data was transmitted from 11/1/23 through 11/19/24. Findings include: A. The agency failed to ensure patients who had Medicare, including Medicare advantage plans and Medicaid insurance plans OASIS data was submitted to CMS. 1. The clinical record for Patient #6 was reviewed on 11/19/24. The plan of care (POC) for the certification period dated 2/14/24 to 4/13/24 revealed a start of care date of 10/17/23; diagnoses included COVID-19, unspecified fall, weakness and unsteadiness on feet. POC orders included physical therapy (PT) visits once a week for one week and twice a week for eight weeks for therapeutic activities, gait training and balance training; and occupational therapy (OT) visits once a week for one week and twice a week for nine weeks for activities of daily living (ADL) retraining. a. The agency failed to ensure Patient #6’s OASIS was transmitted to CMS. On 11/19/24, a review of Patient #6’s insurance information revealed the patient had a Medicare advantage plan. On 11/19/24, review of the Patient #6’s record revealed the patient was discharged from services on 2/27/24. Further review of Patient #6’s record failed to reveal an OASIS that was completed or transmitted to CMS. During an interview on 11/20/24 at 11:24 a.m., the administrator confirmed there was no discharge OASIS that was completed for Patient #6. The administrator also stated the agency had issues regarding clinicians creating and submitting discharge OASIS. B. The agency failed to ensure OASIS data was transmitted within 30 days of completing the assessment. 1. Review of the OASIS Error detail report from 11/1/24 through 11/19/24 revealed five assessments which pertained to 3 different patients, which were submitted more than 30 days after the “M0090” date which was the last date information used to complete the the comprehensive assessment and determine the OASIS coding gathered by the assessing clinician. 2. Review of the OASIS error report for 11/1/24 t 11/19/24 revealed Patient #4 had his OASIS submitted for the following assessments - an assessment was created on 10/19/23 and transmitted on 11/28/23 or 40 days after the M0090 date - an assessment was created on 12/18/23 and transmitted on 2/8/24 or 52 days after the M0090 date - an assessment was created on 4/15/24 and transmitted on 6/3/24 or 49 days after the M0090 date 3. Similar findings were found for Patients #1 and #2. 4. During an interview on 11/20/24 at 11:24 a.m., the administrator stated the agency had issues ensuring the OASIS reports were submitted in a timely manner. The administrator stated she had identified and was working on a plan to fix this issue.”

“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 ensure a discharge summary was sent to the primary care practitioner within five business days of discharge and a transfer summary sent within two business days of becoming aware of a patient’s transfer for 1 of 2 discharged patients records reviewed (Patients #7). Findings include: 1. The clinical record for Patient #6 was reviewed on 11/18/24. The plan of care (POC) for the certification period dated 9/12/24 to 11/10/24 revealed a start of care date of 1/26/22; diagnoses down syndrome, congenital hypotonia, and specified developmental disorder of motor function. POC orders included skilled nursing (SN) visits once every 60 days for assessment and recertification; and certified nursing aide (CNA) visits twice a day for 60 for assistance with all activities of daily living (ADL). a. The agency failed to send Patient #7’s discharge summary to the physician within five business days of the patient’s discharge. Review of Patient #7’s clinical record revealed the patient was discharged from the agency on 10/15/24. Further review of the clinical record failed to reveal the agency had completed a discharge summary. Further review also revealed no notification had been sent to the physician regarding the discharge of Patient #7 from the agency. During an interview on 11/20/24 at 11:24 a.m., the administrator stated a clinician had completed a skilled nursing note on 10/15/24 which was the discharge summary. The administrator also stated the note was poorly documented and it was not sent to the physician within the five business days. The administrator reviewed the clinical record for Patient #7 and confirmed no discharge summary was sent to the physician.”

“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 interviews and record reviews, the agency failed to ensure the Registered Nurse (RN) or applicable rehabilitation skilled professional conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral, or on the physician ordered start of care (SOC) date, for 2 of 2 clinical records reviewed whose SOC was completed by a physical therapist (PT) (Patients #2 and #3). Findings include: 1. The clinical record for Patient #2 was reviewed on 12/8/23. The plan of care for the certification period dated 11/21/23 to 1/19/24 revealed a SOC date of 11/21/23; primary diagnoses included chronic kidney disease stage 3, unspecified abnormalities of gait and mobility, liver transplant status, other amnesia, iron deficiency anemia secondary to blood loss (chronic), and hyperthyroidism, unspecified. Plan of care orders included physical therapy (PT) two times weekly for eight weeks visits to maximize functional capacity and safe mobility. a) The agency failed to start services for Patient #2 on a Physician’s SOC date. Record review revealed a physician’s order for home health to conduct a SOC assessment for Patient #2 on 11/10/23 that was later extended one week to 11/17/23. Review of the SOC completed by PT #2 on 11/21/23 revealed the agency initiated services on 11/21/23. This was four days after the physician’s ordered start of care of 11/17/23. Further record review failed to show PT #2 communicated with Patient #2’s physician and received authorization to delay the initial comprehensive assessment. 2. The clinical record for Patient #3 was reviewed on 12/8/23. The plan of care for the certification period dated 10/31/23 to 12/29/23 revealed a SOC date of 10/31/23; primary diagnoses included sepsis, unspecified organism, hyperlipidemia, type 2 diabetes mellitus without complications, essential [primary] hypertension, transient cerebral ischemic attack, unspecified, multiple sclerosis, urinary tract infection, site not specified, weakness and difficulty in walking, not elsewhere classified. Plan of care orders included PT two times weekly for nine weeks visits to maximize functional capacity and safe mobility. a) The agency failed to start services for Patient #3 within 48 hours of referral. Review of the referral, received on 10/26/23, revealed Patient #3 was scheduled to discharge home on 10/27/23 from the hospital. Review of the SOC completed by PT #2 on 10/31/23 revealed the agency initiated services on 10/31/23. This was four days after the agency accepted the referral and the patient was discharged from the hospital. Further record review failed to show PT #2 communicated with Patient #3’s physician and received authorization to delay the initial comprehensive assessment. 3. During an interview on 12/11/23 at 1:56 p.m., PT #2 stated the planned SOC date for Patient #2 was on 11/10/23, but per patient’s spouse request, the SOC date was extended for one week to 11/17/23. When the agency was unable to meet a SOC date within 48 hours, PT# 2 stated he called the physician for an order to delay the SOC and this was documented in communication notes in the Electronic Medical Record (EMR). However, no documentation was found in EMR and PT#2 acknowledged that there was no communication documented prior to the SOC. During an interview on 12/11/23 at 2:23 p.m., Employee #3 stated that as the intake coordinator, he accepted referrals after confirming insurance information and availability of agency clinicians; He stated the individual cases were assigned to available staff to complete SOC assessments within the 48 hour requirement per regulation. Employee #3 stated when a SOC was delayed, he would contact the hospital case manager to inform a physician for a verbal order (VO), Employee #3 stated he had received an electronic mail from PT #2 to request a delayed SOC for Patient #2 per family request. He further stated he emailed the hospital case manager but acknowledged he did not follow up to ensure the physician authorization to delay the SOC had been received.. During an interview on 12/11/23 at 4:00 p.m., the administrator confirmed the physician’s orders were not followed by the agency regarding the start of care time frames for Patients #2 and #3.”