Adoration Home Health

“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 the Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report, agency policy, and staff interview, it was determined that the agency failed to electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the CMS system every 30 days. Findings include: Review of the policy titled “Reporting of OASIS DATA CAPTURE, TRASMISSION, VERIFICATION, DISPLAY AND REPORTS,” revised 03/01/21 revealed the following: 2. Transmittal of OASIS data a. At least monthly, Agency will electronically transmit accurate, completed, encoded and locked OASIS data to the state agency. All OASIS assessments completed must be transmitted within thirty (30) DAYS OF M0090 date (date the assessment is actually completed). Review of CMS report titled “HHA Error Summary by Agency,” with a run date of 10/31/2024, revealed the agency failed to transmit OASIS data to the CMS system within 30 days. On 11/13/2024 at 2:00 p.m., an in-office video call interview was conducted with the Quality Review Manager and the Administrator. The Quality Review Manager confirmed awareness of the 30-day OASIS submission timeframe requirements not met in August 2023. The Quality Review Manager acknowledged during August 2023, OASIS data gathering was in process of being centralized to one department and the process was slow which caused some delay in submitting OASIS data in a timely manner but has since been corrected.”

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on record reviews and staff interviews, it was determined that the agency’s skilled professional staff failed to provide services as ordered by the physician in the plan of care for one patient (P) (P1). Specifically, the Registered Nurse (RN) failed to provide wound care for P1 and investigate the complaint filed by P1. Findings include: The clinical record for P1 revealed that the RN was required to visit the patient two times a week, Tuesday and Friday, for wound vac (a treatment that uses suction to help wounds heal) changes however, P1 was seen at the time of admission on 3/13/2024. P1 was made a non-admit (notice that the patient is not going to be having home health services) on 3/15/24. Review of document titled Clinical Coordination Note Report dated 3/17/24 as a late entry for 3/16/24, revealed P1 placed call to agency on 3/16/24 at 6:23 pm requesting a visit for wound care to change wound vac (a treatment that uses suction to help wounds heal) dressing. The on-call nurse documented that she made multiple calls and left a message for P1 but did not send a nurse to perform wound care. The physician was not notified. P1 placed a second call at 10:07 pm to request a visit for wound care to change wound vac. The on-call nurse documented that she was told by the Patient Care Manager (PCM) to send P1 to the emergency room for wound care. The doctor was not notified. No resolution was documented. Clinical record for P1 revealed that agency failed to inform the physician that agency cannot meet the needs of the patient. Agency failed to assist the patient in choosing an alternative entity by identifying those entities in the patient’s geographic area that may be able to meet the patient’s wound care needs. On 9/3/2024 at 12:30 pm an interview with the Clinical Director confirmed that P1 was admitted to home health services on 3/13/2024, however P1 was made a non-admission on 3/15/2024 as the agency did not have sufficient staff to provide wound care. P1 failed to receive further visits and failed to be transferred to another provider to assume care. On 9/4/24 at 9:00 am, the Clinical Director further revealed that the agency had had only one Registered Nurse and one Licensed Practical Nurse to provide care. The clinical director stated that there were no reported cases of Covid with their nursing staff at that time, but that there were safety concerns as P1 lived in an isolated area with no cell phone service and also that the agency did not have sufficient staff to provide care. On 9/4/2024 at 9:30 am, an interview conducted with the Patient Care Manager (PCM) revealed that P1 was referred to emergency services for a dressing change as the agency did not have sufficient staff to provide wound care. The PCM further acknowledged that P1 was referred to emergency services for a dressing change as there was not sufficient staff to provide wound care.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on record review, review of policy titled “Patient Discharge/Transfer Process,” and staff and patient interview, it was determined the agency failed to provide wound care per the physician order and the care plan and communicate discharge plans for one patient (P) (P1) prior to discharge from the agency. Findings include: Review of the policy titled “Patient Discharge/Transfer Process,” revised date 10/01/23 revealed the following: 3. Revisions to plan for patient’s discharge will be communicated to : a. Patient b. Patient’s representative if any c. Caregiver if any d. All physicians issuing orders e. Patient’s primary care practitioner of health care professional who will provide care and services to patient after discharge, if any 4. If a patient is discharged because the agency can no longer meet the needs of the patient, the agency will assist the patient/patient representative in choosing an alternate provider that can meet the patient’s needs. Documentation will support that the patient was informed that the agency can no longer meet his/her needs and alternatives provided to patient. Review of the clinical record revealed the agency failed to provide discharge communication to P1 prior discharge. The clinical record failed to reveal documented discharge instructions, and the agency failed to notify the physician of P1 discharge. An interview on 9/4/2024 at 10:45 am with P1 revealed that (P1) was not told that the agency had discharged (P1) and did not receive a call from the agency to let (P1) know that (P1) would be receiving care from another agency. An interview on 9/4/2024 at 11:00 am with the Executive Director revealed that P1 was a non-admission, and a discharge summary was not completed. The Executive Director could not confirm whether P1 had been informed that he was made a non-admission.”

“Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This Condition is not met as evidenced by: Based on record review, review of policy titled “Plan of Care (POC), and patient and staff interviews, it was determined that the agency failed to provide services as ordered by the physician in the plan of care and to communicate and coordinate wound care management with physician and other health care practitioners for one patient (P) (P1). Findings include: Review of the policy titled “Plan of Care (POC),” revised 09/01/24 reveals the following: PURPOSE: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician/authorized practitioner’s orders are followed. The clinical record revealed that a skilled nurse was required to visit P1 two times a week, Tuesday and Friday, for wound vac (a treatment that uses suction to help wounds heal) changes, however, patient was seen at the time of admission on 3/13/24, and no further visits revealed. Review of document titled “Client Coordination Note Report,” dated 3/17/2024 failed to reveal the physician was notified of agency not able to provide wound care to the patient and advising P1 to seek emergent care. Further review of the clinical record failed to reveal that the agency assisted P1 in choosing an alternative entity by identifying those entities in the patient’s geographic area that may be able to meet the patient’s wound care needs. Clinical record failed to reveal physician was notified of not meeting the patient’s wound care needs. On 9/3/2024 at 12:00 pm an interview with the Executive Director confirmed that P1 was admitted on 3/13/2024 and made a non-admission on 3/15/2024. On 9/3/2024 at 12:30 pm an interview with the Clinical Director confirmed that P1 was admitted to home health services on 3/13/2024 however he was made a non-admission on 3/15/2024 as the agency did not have sufficient staff to provide wound care. P1 failed to receive further visits and failed to be transferred to another provider to assume care. A call was placed on 9/3/2024 1:33 pm to P1. It was confirmed that an initial visit had been made. P1 states that on 3/16/2024 P1 made several calls to the agency to request a nursing visit for wound care as (P1) supplies had been delivered. P1 stated that (P1) was told that someone was coming. P1 called again on 3/16/2024 as the nurse did not arrive and was told to go to the emergency room and was transported via ambulance. P1 was not admitted and returned home. P1 was unable to give exact dates but stated that (P1) had been to the emergency room on three different times seeking care for (P1) wound. P1 states that (P1) primary care doctor made a referral to another agency and was admitted on 3/29/2024. On 9/4/24 at 9:00 am, an interview with the Clinical Director revealed that the agency had only one Registered Nurse and one Licensed Practical Nurse to provide care. The clinical director revealed that there were safety concerns as P1 lived in an isolated area with no cell phone service and also that the agency did not have sufficient staff to provide care. On 9/4/2024 at 9:30 am an interview conducted with the Patient Care Manager (PCM) revealed that P1 was referred to emergency services for a dressing change as the agency did not have sufficient staff to provide wound care.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on record review, review of policy titled “Plan of Care (POC), policy titled, “Patient Discharge/Transfer Process,” and patient and staff interviews, it was determined that the agency failed to provide services as ordered by the physician in the plan of care and to communicate and coordinate wound care management with physician and other health care practitioners for one patient (P) (P1). Findings include: Review of the policy titled “Plan of Care (POC),” revised 09/01/24 reveals the following: PURPOSE: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician/authorized practitioner’s orders are followed. Review of the policy titled “Patient Discharge/Transfer Process,” revised date 10/01/23 revealed the following: 3. Revisions to plan for patient’s discharge will be communicated to : a. Patient b. Patient’s representative if any c. Caregiver if any d. All physicians issuing orders e. Patient’s primary care practitioner of health care professional who will provide care and services to patient after discharge, if any The clinical record revealed that a skilled nurse was required to visit the P1 two times a week, Tuesday and Friday, for wound vac (a treatment that uses suction to help wounds heal) changes, however, patient was seen at the time of admission on 3/13/24, and no further visits revealed. Review of document titled “Client Coordination Note Report,” dated 3/17/2024 failed to reveal the physician was notified of agency not able to provide wound care to the patient and advising P1 to seek emergent care. Further review of the clinical record failed to reveal that the agency assisted P1 in choosing an alternative entity by identifying those entities in the patient’s geographic area that may be able to meet the patient’s wound care needs. Clinical record failed to reveal physician was notified of not meeting the patient’s wound care needs. On 9/3/2024 at 12:00 pm an interview with the Executive Director confirmed that P1 was admitted on 3/13/2024 and made a non-admission on 3/15/2024. On 9/3/2024 at 12:30 pm an interview with the Clinical Director confirmed that P1 was admitted to home health services on 3/13/2024 however he was made a non-admission on 3/15/2024 as the agency did not have sufficient staff to provide wound care. P1 failed to receive further visits and failed to be transferred to another provider to assume care. A call was placed on 9/3/2024 1:33 pm to P1. It was confirmed that an initial visit had been made. P1 states that on 3/16/2024 (P1) made several calls to the agency to request a nursing visit for wound care as (P1) supplies had been delivered. P1 stated that (P1) was told that someone was coming. P1 called again on 3/16/2024 as the nurse did not arrive and was told to go to the emergency room and was transported via ambulance. P1 was not admitted and returned home. P1 was unable to give exact dates but stated that (P1) had been to the emergency room on three different times seeking care for wound. P1 states that (P1) primary care doctor made a referral to another agency and was admitted on 3/29/2024. On 9/4/2024 at 9:00 am, an interview with the Clinical Director revealed that the agency had only one Registered Nurse and one Licensed Practical Nurse to provide care. The clinical director revealed that there were safety concerns as P1 lived in an isolated area with no cell phone service and also that the agency did not have sufficient staff to provide care. On 9/4/2024 at 9:30 am an interview conducted with the Patient Care Manager (PCM) revealed that P1 was referred to emergency services for a dressing change as the agency did not have sufficient staff to provide wound care.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review, review of policy titled “Plan of Care (POC), policy titled, “Patient Discharge/Transfer Process,” and patient and staff interviews, it was determined that the agency failed to provide services as ordered by the physician in the plan of care and to communicate and coordinate wound care management with physician and other health care practitioners for one patient (P) (P1). Cross reference G0940 as it relates to P1-Organization and administration of services.”

“HHA can no longer meet the patient’s needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient’s welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient’s needs, based on the patient’s acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA’s capabilities; This Element is not met as evidenced by: Based on record reviews and staff interviews, it was determined that the agency’s skilled professional staff failed to provide services as ordered by the physician in the plan of care for one patient (P) (P1), Specifically, the skilled nurse (SN) failed to provide wound care for P1. Findings include: The clinical record for P1 revealed that SN was required to visit the patient two times a week, Tuesday and Friday, for wound vac (a treatment that uses suction to help wounds heal) changes however, P1 was seen at the time of admission on 3/13/2024. P1 was made a non-admit (notice that the patient is not going to be having home health services) on 3/15/24. Clinical record for P1 revealed that agency failed to inform the physician that agency cannot meet the need of the patient. On 9/3/2024 at 12:30 pm an interview with the Clinical Director confirmed that P1 was admitted to home health services on 3/13/2024, however P1 was made a non-admission on 3/15/2024 as the agency did not have sufficient staff to provide wound care. P1 failed to receive further visits and failed to be transferred to another provider to assume care. On 9/4/24 at 9:00 am an interview with the Clinical Director revealed that agency had only one Registered Nurse and one Licensed Practical Nurse to provide care. The clinical director revealed that there were safety concerns as P1 lived in an isolated area with no cell phone service and also that the agency did not have sufficient staff to provide care. On 9/4/2024 at 9:30 am, an interview conducted with the Patient Care Manager (PCM) revealed that P1 was referred to emergency services for a dressing change as the agency did not have sufficient staff to provide wound care. Cross references G0406 as it relates to P#1- Patient’s Rights”

“Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient’s representative (if any), and the patient’s caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This Element is not met as evidenced by: Based on review of clinical records and staff interviews, the agency failed to investigate complaints made of care furnished inconsistently and neglect. The agency failed to send Registered Nurse (RN) to visit patient (P) (P1) for wound care assistance. Cross references L0406 as it relates to P1- Patient’s Rights”

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s 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). This Element is not met as evidenced by: Based on record review, review of policy titled “Patient Discharge/Transfer Process,” and staff and patient interview, it was determined the agency failed to communicate discharge plans for one patient (P) (P1) prior to discharge from the agency. Review of the policy titled “Patient Discharge/Transfer Process,” revised date 10/01/23 revealed the following: 3. Revisions to plan for patient’s discharge will be communicated to : a. Patient b. Patient’s representative if any c. Caregiver if any d. All physicians issuing orders e. Patient’s primary care practitioner of health care professional who will provide care and services to patient after discharge, if any 4. If a patient is discharged because the agency can no longer meet the needs of the patient, the agency will assist the patient/patient representative in choosing an alternate provider that can meet the patient’s needs. Documentation will support that the patient was informed that the agency can no longer meet his/her needs and alternatives provided to patient. Review of the clinical record revealed the agency failed to provide discharge communication to P1 prior discharge. The clinical record failed to reveal documented discharge instructions, and the agency failed to notify the physician of P1 discharge. An interview on 9/4/2024 at 10:45 am with P1 revealed that (P1) was not told that the agency had discharged and that (P1) did not receive a call from the agency to let (P1) know that (P1) would be receiving care from another agency. Cross references G0570 as it relates to P1- care planning, coordination, and quality of care.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review, review of policy titled “Plan of Care (POC), and patient and staff interviews, it was determined that the agency failed to provide services as ordered by the physician in the plan of care for patient (P) (P1). Findings Include: Review of the policy titled “Plan of Care (POC),” revised 09/01/24 reveals the following: PURPOSE: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician/authorized practitioner’s orders are followed. The clinical record revealed that a skilled nurse was required to visit the patient two times a week, Tuesday and Friday, for wound vac (a treatment that uses suction to help wounds heal) changes, however, patient was seen at the time of admission on 3/13/24, and no further visits revealed. Cross reference G0700 as it relates to P1- Skilled professional services.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on record review and staff interview, the agency failed to communicate and coordinate wound care management with physician and other health care practitioners for one patient (P) (P1). Findings include: Review of document titled “Client Coordination Note Report,” dated 3/17/2024 failed to reveal the physician was notified of agency not able to provide wound care to the patient and advising P1 to seek emergent care. Cross references G0700 as it relates to P1- Skilled professional services.”

“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 record reviews, review of policy titled “Patient Discharge/Transfer Process,” and staff interviews, it was determined that the agency failed to complete a discharge summary which includes, admission and discharge dates, physician responsible for the Home Health plan of care, reason for admission to home health, types of services provided to the patient, medications the patient is on at the time of discharge, patient’s discharge condition, patient outcomes in meeting the goals in the pan of care and patient and family post-discharge instructions. Specifically, the agency failed to provide the discharge summary to the physician and to the health care provider who will be responsible for care and services to the patient after discharge from the current agency. Findings include: Review of the agency policy titled ““Patient Discharge/Transfer Process,” revised 10/01/23 reveals the following: 21. A discharge summary including admission and discharge dates, reason for admission to home health, reason for discharge, services provided to the patient, patient’s condition at time of discharge, a brief summary of care provided, progress towards goals, patient’s discharge goals of care, patient’s treatment preferences, a list of community resources or referrals made, along with a current medication list is sent to the physician or other healthcare professional responsible for care after discharge from the agency within 5 business days of patient’s discharge. Review of P1’s record revealed that P1 was admitted to home health agency on 3/13/2024 and P1 was made a non-admit (notice that the patient is not going to be having home health services) on 3/15/2024. On 9/3/24 at 12:30 pm, an interview with the Clinical Director confirmed that P1 was admitted to home health services on 3/13/2024. However, P1 was made a non-admission on 3/15/2024. On 9/4/24 at 11:00 am, an interview with the Executive Director revealed that P1 was a non-admission, and a discharge summary was not completed. Clinical record failed to reveal a completed discharge summary for P1.”