Human Touch Home Health Care Agency Denver Inc.

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on interview and record review, the agency failed to provide patients with the home health agency’s administrator’s name, business address, and business phone number in order to receive complaints for 2 of 4 patients reviewed (Patients #1 and #4). Findings include: 1. Review of Patient #1’s record revealed a start of care date of 11/5/24. Diagnoses include benign intracranial hypertension. Orders included physical therapy visits two times a week for nine weeks effective 11/5/24. a. The agency failed to provide patients with the current agency administrator’s name and business contact information in order to receive complaints. Review of the admissions packet for Patient #1 revealed it was signed on 11/5/24. The document failed to reveal the name, business address, or business phone number for the agency administrator. During an interview on 12/30/24 at 10:08 a.m., the administrator/director of nursing (DON) stated she was hired as the administrator and DON on 10/21/24. Review of a blank general admissions packet provided by the agency on 12/30/24 revealed a previous administrator’s name, business address, and business phone number. During an interview on 12/30/24 at 10:57 a.m. with the corporate financial manager and the administrator/DON, it was stated that the previous administrator left the agency in August, 2024. 2. Review of Patient #4’s record revealed similar findings. 3. During an interview on 12/30/24 at 1:10 p.m. with the administrator/DON and the regional operations manager, staff admitted that the admissions packets provided to Patients #1 and #4 were not up to date. The admissions paperwork did not include the current administrator’s name, business address and phone number. Staff stated they will correct the admissions information promptly.”

“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 interview and record review of the Centers for Medicare and Medicaid Services (CMS) Outcome and Assessment Information Set (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 65 patients who received an assessment from 3/1/24 through 5/15/24 and the agency failed to submit 448 assessments within the 30 day timeframe for assessments submitted from 6/1/23 through 5/15/24. Findings include: 1. Review of the OASIS Error Detail report from 3/1/24 through 5/15/24, revealed 79 assessments, which pertained to 65 different patients, were submitted more than 30 days after the “M0090” date, which was the last date information used to complete the comprehensive assessment and determine the OASIS coding gathered by the assessing clinician. Review of the OASIS Error Detail report from 6/1/23 through 5/15/24, revealed 448 assessments were submitted more than 30 days after the M0090 date. 2. During an interview on 5/21/24 at 12:34 p.m., the director of nursing (DON) stated she was responsible for keeping track of when to submit an OASIS assessment and for submitting OASIS assessments. The DON stated the reason the agency had 448 assessments submitted after the 30 day timeframe for assessments submitted from 6/1/23 through 5/15/24 was multifactorial which included: issues with turnover in the agency and issues with the agencies electronic medical record (EMR) system. The DON stated the agency’s EMR was not retaining information entered by clinicians during their assessments. The DON stated when this occurred, the agency administrative team would instruct the clinician to reenter assessment information, thus delaying the submission of the assessment. The DON stated the other issue with the agency EMR the agency was experiencing was the EMR was not transmitting data from assessments accurately to the Internet Quality Improvement and Evaluation system (iQIES). The DON stated she would submit assessments to iQIES and would receive a report back indicating which assessments were accepted and which were rejected. The DON stated the report returned appeared to be omitting some assessments, thus the DON was unaware the assessment was not accepted. The DON stated the agency had a third party billing company who provided the agency with a different report which would alert the DON when an assessment had not been submitted and the DON used that report to catch the assessments which were omitted on the iQIES submission report. The DON stated she used to receive the billing report every two weeks to once a month, but due to the issues the agency was facing with late submission of assessments, she had recently requested the billing report be sent to her weekly to attempt to correct this deficiency. 3. Review of the OASIS validation report for 6/1/23 through 4/31/24 revealed Patient B had his OASIS submitted on 5/15/24, for an assessment that had been completed on 12/27/23, approximately 141 days after the completion of the assessment. During an interview on 5/21/24 at 12:48 p.m., the DON stated she could not recall the exact reason Patient B’s 12/27/23 assessment was submitted 141 days after the completion date. The DON stated she thought Patient B’s 12/27/23 assessment was likely an assessment omitted on the iQIES transmission report for the first time it was submitted, and the error was not caught by the billing report until May 2024, and thus, submitted on 5/15/24. 4. Review of the OASIS validation report for 3/1/24 through 5/15/24/24 revealed Patient C had her OASIS assessment submitted on 5/15/24, for an assessment that had been completed on 3/11/24, 66 days after the completion of the assessment. During an interview on 5/21/24 at 12:53 p.m., the DON stated she could not recall the exact reason Patient C’s 3/11/24 assessment was submitted 66 days after the completion date. The DON stated Patient C’s 3/11/24 assessment was completed by the clinician on 3/12/24. The DON stated she thought Patient C’s 3/11/24 assessment was likely an assessment omitted on the iQIES transmission report for the first time it was submitted, and the error was not caught by the billing report until May 2024, and thus, submitted on 5/15/24. 5. Review of the OASIS validation report for 3/1/24 through 5/15/24 revealed Patient A had his OASIS submitted on 5/15/24, for an assessment that had been completed on 4/1/24, approximately 45 days after the completion of the assessment. During an interview on 5/21/24 at 12:46 p.m., the DON stated she did not receive Patient A’s 4/1/24 discharge assessment until 4/24/24. The DON stated she thought Patient A’s 4/1/24 assessment was likely an assessment omitted on the iQIES transmission report for the first time it was submitted, and the error was not caught by the billing report until May 2024, and thus, submitted on 5/15/24. 5. Similar findings of the agency failing to submit accurate OASIS assessments within the 30 day timeframe required by regulation was found for assessments submitted for the other 445 assessments reviewed on the agency’s OASIS validation report from 6/1/23 to 5/15/24.”

“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 interview and record review, the agency failed to ensure each patient’s plan of care (POC) included accurate parameters, all medications, and accurate types of services to be provided for 3 of 9 active patients reviewed (Patients #2, #7 and #9). Findings include: 1. The clinical record for Patient #2 was reviewed on 5/20/24. The POC for the certification period dated 4/13/24 to 6/11/24 revealed a start of care date of 6/23/22; diagnosis included cerebral infarction, type 2 diabetes mellitus with hyperglycemia, Moyamoya disease, hypertension, hyperlipidemia, cholecystitis, history of respiratory arrest, schizoaffective disorder, and weakness. Plan of care orders included skilled nursing (SN) visits five times a week for nine weeks for assessment, education and to assist with diabetic management; home health aide (HHA) visits five times a week for nine weeks to safely assist with activities of daily living (ADL); physical therapy (PT) visits two times a week for nine weeks for therapeutic exercise, therapeutic activities, gait training, balance training, home exercise program (HEP) education and caregiver education; and occupational therapy (OT) visits three times a week for two weeks, one time a week for one week, and three times a week for six weeks for home safety assessment, training and management of adaptive equipment, ADL training, adaptive homemaking skills training, upper extremity strengthening, and caregiver training. a) The agency failed to ensure Patient #2’s POC included accurate blood sugar parameters. Review of the POC failed to show blood sugar parameters were documented in the specific interventions/education section of the POC. Review of the measurable outcomes and goals section of the POC, a goal was listed which stated the registered nurse (RN) would notify the patient’s physician if her blood sugar was either greater than 200 or less than 70. Review of the additional information section of the POC showed the RN would call Patient #2’s physician if her blood sugar was greater than 400. During an interview on 5/22/24 at 11:25 a.m., RN #10 confirmed she was the primary SN who provided care to Patient #2 five days a week. RN #10 stated at each visit she obtained Patient #2’s blood sugar and administered her insulin based on her sliding scale. RN #2 stated if Patient #2’s blood sugar was above 400, she would call Patient #2’s physician as directed on the POC. RN #2 stated she was not aware the POC also stated to call Patient #2’s physician if her blood sugar was lower than 70 or greater than 200. RN #2 stated a previous RN might have included the parameters listed in the goals section of the POC to call Patient #2’s physician if her blood sugar was greater than 200 or lower than 70. RN #2 stated she would and had called Patient #2’s physician when Patient #2’s blood sugar was over 400. RN #2 stated if Patient #2 had a blood sugar lower than 100 she would also call Patient #2’s physician, but acknowledged she did not have an order for this parameter. RN #10 stated she would reach out to Patient #2’s physician to clarify Patient #2’s blood sugar parameters. 2. The clinical record for Patient #9 was reviewed on 5/20/24. The POC for the certification period dated 4/19/24 to 6/1724 revealed a start of care date of 4/19/24; diagnosis included hemiplegia and hemiparesis following a cerebral infarction, dysarthria and anarthria, hypoxemia, chronic obstructive pulmonary disease, septic pulmonary embolism, hypertension and tobacco use. Plan of care orders included PT visits one time a week for one week and two times a week for eight weeks for strengthening, gait, functional mobility, and endurance training, HEP education, and neuro-muscular reeducation; OT visits two times a week for seven weeks for self care retraining, instrumental ADL retraining, mobility training, therapeutic exercise and patient education; and speech language and pathology (SLP) visits one time a week for one week and one week a week for four weeks for strategies for memory recall, activities for word finding, concentration, and comprehension, problem solving and thinking and executive function retraining. a) The agency failed to ensure Patient #9’s POC included a medication list. Review of the POC failed to show a medication list. Review of referral documentation sent to the agency on 4/18/24 by the referring hospital showed Patient #9 was taking: -Atrovent 12.9 grams (gm) inhaler one puff metered dose twice daily; -Flovent 220 micrograms (mcg) inhaler one puff metered dose twice daily; -Advair 500 -50 diskus one puff metered dose twice daily; and -Lisinopril 20 milligrams (mg) orally once daily. During an interview on 5/21/24 at 2:24 p.m., Patient #9’s wife stated Patient #9 returned home from the hospital on 4/19/24 and was prescribed Lisinopril 20 mg. Patient #9’s wife also stated Patient #9 currently took the following medications: Lisinopril 20 mg; Levothyroxine 50 mcg; Rosuvastatin 20 mg; a men’s multivitamin; a baby aspirin, and Chantix to help him quit smoking. Patient #9’s wife stated she thought PT #11 reviewed Patient #9’s medications with Patient #9 and his wife during Patient #9’s first home care visit on 4/19/24. During an interview on 5/22/24 at 11:45 a.m., PT #11 confirmed she was Patient #9’s primary PT and completed Patient #9’s start of care comprehensive assessment on 4/19/24. PT #11 stated when she completed a start of care assessment she would review a patient’s referral information to see if a medication list was included. PT #11 stated she would bring the referral medication list to the first visit and review this list with the patient to verify if he/she was still taking the medication documented on the list. PT #11 stated she would then use the information gathered from the referral list and the patient to create the medication list on the patient’s POC. PT #11 stated she also asked patient’s at each visit if they had started or stopped any medications since their last visit. If a patient had changed their medications, the PT would notify the patient’s physician and write an order to update the POC. PT #11 stated she reviewed what medications Patient #9 was taking at his start of care visit. PT #11 acknowledged she failed to document what medication’s Patient #9 was taking on his POC as she forgot. 3. The clinical record for Patient #7 was reviewed on 5/21/24. The POCs for the certification periods dated 2/16/24 to 4/15/24 and 4/16/24 to 6/14/24 revealed a start of care date of 2/21/23; diagnosis included schizoaffective disorder and fracture of left shoulder girdle with routine healing. Plan of care orders included SN visits one time a month for two months and three as needed (PRN) visits for assessment and monthly intramuscular injections of 117 mg of Invega to manage schizoaffective disorder; PT evaluation and treatment; and OT evaluation and treatment. a) The agency failed to ensure the POC included an accurate list of disciplines providing care to the patient. Review of the clinical record showed Patient #7 had received three PT visits on 3/11/23, 3/15/23 and 3/17/23. The clinical record failed to show Patient #7 had received any further PT visit after 3/17/23. During an interview on 5/22/24 at 10:43 a.m., RN #12 confirmed she was Patient #7’s primary SN and responsible for completing Patient #7’s recertification comprehensive assessments and recertification POCs. RN #12 stated Patient #7 had received a few PT visits when she started to receive care from the agency in February of 2023. RN #12 stated PT #13 determined Patient #7 did not require further treatment and thus discharged Patient #7 from services. RN #12 stated Patient #7 was currently receiving SN and OT visits. RN #12 stated she was not aware the POCs for the certification periods dated 2/16/24 to 4/15/24 and 416/24 to 6/14/24 contained orders for PT to evaluate and treat. RN #12 stated she had only requested from the physician and documented orders for OT and SN for both certification periods. RN #12 stated the PT evaluation and treat orders might have carried over from her initial order for Patient #7 at her start of care on 2/21/23. 4. During an interview on 5/22/24 at 2:57 p.m., the administrator and the director of nursing (DON) stated the DON was responsible for reviewing patients’ POCs for accuracy. The DON stated the agency’s electronic medical record (EMR) system transferred information from a patient’s comprehensive assessment to generate the patient’s POC. The DON stated the EMR also transferred old information gathered during previous assessments to the POCs as well, thus one of the DON’s responsibility was to review patient’s POCs for accuracy and remove redundant or inaccurate information. The DON acknowledged she failed to miss the conflicting blood sugar parameters on Patient #2’s POC or the inaccurate PT eval and treat order on Patient #7’s POCs for the certification periods dated 2/16/24 to 4/15/24 and 4/16/24 to 6/14/24. The DON stated she did note Patient #9s POC was missing a medication list when she originally reviewed his POC. The DON and administrator stated the DON sent an email to PT #12 on 4/25/24 requesting she add Patient #9’s medications to his POC; and PT #12 sent a return email on 4/25/24 acknowledging she had failed to add Patient #9’s medications to his POC and she would complete this task. The DON and the administrator acknowledged as of the interview (28 days later), PT #12 had not added Patient #9’s medication list to his POC.”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on interview and record review, the agency failed to provide ongoing education and training to the patient and patient’s caregiver for the care and services identified in the plan of care and tasks delegated to the patient/caregiver to meet the needs of the patient for 1 of 1 patient reviewed who received skilled nursing (SN) for diabetic management (Patient #2). Findings include: 1. The clinical record for Patient #2 was reviewed on 5/21/24. The plan of care for the certification period dated 4/13/24 to 6/11/24, revealed a start of care date of 6/23/22; diagnosis included cerebral infarction (stroke), type 2 diabetes mellitus (DM), moyamoya disease (brain disease), cholecystitis (inflammation of the gallbladder), hypertension, weakness and schizoaffective disorder. Plan of care service orders included skilled nursing (SN) five times a week and two visits as needed (PRN) for system assessment, change of freestyle glucose monitor as needed, check blood sugar (BS) and administer insulin; certified nurse assistant (CNA) services five times a week; and occupational therapy (OT) services three times a week. Plan of care for medication administration included giving insulin 40 units Lantus and Humalog per the sliding scale (SS) (based on blood glucose readings) in the mornings, and family (patient’s daughter) to check BS and administer insulin in the evenings and weekends. Plan of care for education and training order included SN to assess patient/caregiver ability to manage diabetic process, instruct caregiver on insulin preparation, administration, site rotation, disposal of supplies and develop individualized emergency plan with the patient. a) The agency failed to provide ongoing education and training to Patient #2’s caregiver (patient’s daughter) in the provision of home health services related to diabetic management for Patient #2 to ensure effective delivery of care and services to meet the patient’s needs. Clinical record review revealed Patient #2 was care planned to receive blood glucose checks three times a day, Lantus two times a day and Humalog per SS three times a day. The plan of care included a goal of maintaining blood glucose levels between 70 and 200. Instructions on the plan of care included to notify the medical doctor (MD) if the blood glucose was less than 70 or greater than 200 and if BS level is greater than 400. No documentation was found clarifying which high BS reading was the basis to notifying MD. However, Patient #2’s caregiver was noted to have a knowledge deficit related to a low and high blood sugar parameter and reporting requirement. 2. During a home visit on 5/22/24 and interview at approximately 6:15 a.m., Patient #2’s caregiver stated she didn’t know about the BS parameter, what to do if the BS was too high or too low and the need to notify MD. Patient # 2’s caregiver said she offered snacks whenever the patient was shaking and stated she did not receive any training or education from the agency related to a BS parameter and reporting requirement. Patient #2’s caregiver further stated the lowest BS she ever read was 90 and she couldn’t state the highest value she had measured and read. The caregiver stated that she would call 911 if the patient was unable to consume snacks or became unconscious. 3. During an interview on 5/22/24 at 11:25 a.m., RN #10 stated she had provided adequate training and education to Patient # 2’s caregiver including calling MD if BS is greater than 400. RN # 10 stated that she had been arriving at the patient’s home after the CNA completed tasks and the patient consumed breakfast hence the patient had never had any episode of low BS reading. RN # 10 stated Patient # 2’s BS was 410 two years ago and she notified the MD after administering insulin as ordered. RN #10 further stated she would hold insulin and call MD if BS was less than 100 which was not care planned. RN #10 realized the need to have an order and made a phone call after the interview to request a physician’s verbal order to clarify the BS parameter, reporting requirement and interventions for low BS level that requires an intervention and MD notification. 4. During an interview on 5/22/24 at 2:59 p.m., the Director of Nursing (DON) and the Administrator stated they would ensure the agency obtained a physician order to clarify the BS parameter and reporting requirement, provide education and training to Patient #2 and Patient #2’s caregiver, document ongoing education and update Patient #2’s plan of care.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and record review, the agency failed to provide services and treatments only as ordered by the physician for 1 of 1 discharged patient records reviewed (Patient #1). Findings include: 1. The clinical record for Patient #1 was reviewed on 3/28/24. The plan of care for the certification periods dated 1/4/24 to 3/3/24 revealed a start of care date of 1/4/24; diagnoses included enterocolitis (inflammation in the intestinal tract) clostridium difficile, diarrhea and dehydration. Plan of care orders included skilled nursing (SN) services once a week for nine weeks and two as needed (PRN) visits for dressing failure, central venous catheter (CVC) care, blood draws, assessment of body systems, assessment of vitals signs (VS) including pain, assessment of medication use, and patient education. a) The agency failed to obtain updated frequency orders for Patient #1 and exceeded the prescribed number of visits per physician orders for performing CVC dressing changes. Record review of skilled visit notes between the dates of 1/4/24 to 3/3/24 revealed Patient #1 received 19 SN visits. Per physician orders in the plan of care dated 1/4/24 Patient #1 was to receive nine SN visits with two PRN visits for dressing failure. The SN visits exceeded the prescribed amount of SN visits by eight visits total. Record review of the SN visit notes dated 1/22/24, 1/24/24 and 1/27/24, which all occurred within the same week, detailed the following SN tasks performed; on 1/22/24 registered nurse (RN) Case Manager #3 performed patient education of medication use, assessment of all systems, assessment of VS including pain, and sterile dressing change at CVC site; on 1/24/24 RN Case Manager #3 performed patient education of medication use, assessment of all systems, assessments of VS including pain, sterile dressing change at CVC with normal saline flush, and blood draw; 1/27/24 RN Case Manager #3 performed patient education of medication use, assessment of all systems, assessment of VS including pain, and sterile dressing change at CVC site. Similar findings were found for all following weeks up to the end of the certification period on 3/3/24. Review of the clinical record for Patient #1 failed to reveal an updated order from the physician of the patient indicating a need for increased SN visits past the original physician order on 1/4/24. During an interview on 4/1/24 at approximately 12:00 p.m., RN Case Manager #3 stated he had received updated frequency and care orders for Patient #1. RN Case Manager #3 also stated he had received the orders after Patient #1 had an allergic reaction. RN Case Manager #3 went on to state he was performing sterile dressing changes to resolve irritation at the CVC site. RN Case Manager #3 stated he called and spoke to the physician of Patient #1 to receive updated orders. During an interview on 4/1/24 at 1:53 p.m., the Administrator and director of nursing (DON) stated when asked about the expanded frequency orders for Patient #1 they would have to look for them. Furthermore the DON confirmed PRN visits, unless otherwise specified, are for the whole of the certification period and not per week. At the end of the interview at approximately 2:20 p.m., a request list was given to the DON and Administrator regarding the missing physician orders. At the time of the exit interview at 4:30 p.m., the agency was unable to provide the expanded frequency orders.”