Neighborhood Health Care, LLC

“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 review of the Agency’s Emergency Preparedness Plan and Staff interview, it was determined the Agency failed to ensure the Emergency Preparedness Plan was based on an updated facility and community risk assessment, utilizing an all-hazards approach. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 12/23/24 at 11:15 AM. The plan lacked documentation of a Hazard Vulnerability Assessment for 2021, 2022 and 2023. 2. During an interview with the QA RN on 12/24/24 at 1:10 PM, the above finding was confirmed.”

“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 review of the Agency’s Error Summary report and Staff interview, it was determined in 33 of 183 reports submitted for the last 12 months, the Agency failed to submit all timely reports. Finding include: 1. The Agency’s Error Summary report for 12/01/23 thru 11/30/24, was reviewed on 12/24/24 at 12:10 PM. The report included error # -3330 for 33 submissions. 18.03% of the OASIS reports were not submitted timely, resulting in a warning. 2. The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 12/26/24 at 2:00 PM.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on the clinical records reviewed and Staff interview, it was determined in 2 of 7 (Pts. # 2 and 5) clinical records reviewed, the patient care was not provided as ordered in the plan of care. Findings include: 1. Pt. #2 was admitted to the Home Health Services on 08/29/24 with the diagnoses of: Hypothyroidism, Unspecified and Heart Failure, Unspecified. The clinical record was reviewed on 12/24/24. The clinical record contained a POC dated 10/28/24, that required the SN to assess the patient’s weight 1 time a week for 9 weeks and notify the doctor of weight gain/loss greater than 5 pounds. The SN assessed the weight on 12/19/24 as 141 pounds and on 12/24/24 as 155 pounds. The SN failed to notify the doctor of the 14 pounds weight gain. 2. Pt. #5 was admitted to the Home Health Services on 09/05/24 with the diagnosis of: Hypertensive Heart Disease. The clinical record was reviewed on 12/24/24. The clinical record contained a POC dated 11/04/24, that required the SN to assess the patient 1 time a week for 9 weeks. The SN failed to visit/assess the patient week #5. 3. The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 12/26/24 between 11:30 AM and 2:00 PM.”

“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 the clinical records reviewed and Staff interview, it was determined in 2 of 7 (Pts. #3 and 7) clinical records reviewed, the PsOC failed to included all the requirements. Findings include: 1. Pt. #3 was admitted to the Home Health Services on 10/24/24 with the diagnoses of: Arthropathy, Unspecified and Type 2 Diabetes Mellitus. The clinical record was reviewed on 12/24/24. The clinical record contained a POC dated 10/24/24, that required the SN to assess the diabetic patient 1 time a week for 9 weeks. The POC lacked the safety measures, equipment/supplies for the disposal of the diabetic sharps. 2. Pt. #7 was admitted to the Home Health Services on 04/20/24 with the diagnoses of: Unspecified Hyperlipidemia and Type 2 Diabetes Mellitus. The clinical record was reviewed on 12/24/24. The clinical record contained PsOC dated 08/18/24 and 12/23/24, that required the SN to assess the diabetic patient 1 time a week for 9 weeks. The PsOC lacked the safety measures, equipment/supplies for the disposal of the diabetic sharps. 3. The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 12/26/24 between 11:30 AM and 2:00 PM.”

“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 clinical record review and Staff interview, it was determined that in 1 of 2 (Pts. #6) clinical records reviewed, the Agency failed to ensure a completed discharge summary was sent to the physician. Findings include: 1. Pt. #6 was admitted to the Home Health Services on 04/27/24 with the diagnosis of: Essential (Primary) Hypertension. The clinical record was reviewed on 12/26/24. The clinical record lacked a completed discharge summary. The discharged summary lacked the vital signs, written instructions to the patient, signature/title of the person completing the form and documentation that the discharge summary was sent to the physician. 2. The above findings were confirmed, during the interview with the Administrator and Director of Nursing, on 12/26/24 between 11:30 AM and 2:00 PM.”