Good Heart Home Health Care, Inc.

“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 review of the Error Summary report and staff interview, it was determined that in 81 of 458 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 12/01/23 to 11/30/24 (12 months), was reviewed on 12/18/24. The report included a warning for Error # -3330. The Error included 81 (17.69%) of 458 assessments that were submitted late. 2. During an interview with the Administrator and Clinical Supervisor on 12/19/24 at 10:00 AM, the Administrator confirmed that the timeframe for submission of OASIS is within 30 days after completion. During the same interview, the Administrator confirmed the above findings.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on a review of the Pt. admission folder, clinical records, observation during home visits, and staff interviews, it was determined in 6 of 7 (Pts. #2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to ensure the Pt./representative was informed of the services to be provided in writing, and/or the frequency of visits provided by each discipline. Findings include: 1. The Pt. admission folder was reviewed on 12/16/24. The folder contained the form titled, “Admission Consent & Service Agreement” that included the section, “Initial Services and Frequency Service/s to Be Provided and initial Frequency of Visits”. This form is signed by the Pt./representative during the SOC visit, staff provide a copy to the Pt./representative, and the original is returned to the Agency’s office. 2. The following clinical records were reviewed from 12/17/24 to 12/18/24, and lacked documentation of the services to be provided at the SOC, and/or the visit frequency of each service: Pt. #2. SOC 6/24/24 – Lacked SN service and the visit frequency. Pt. #3. SOC 8/2/24 – Lacked SN, PT, and Home Health Aide visit frequencies. Pt. #4. SOC 10/2/24 – Lacked SN, PT, OT services; and the visit frequencies. Pt. #5. SOC 11/19/24 – Lacked SN, PT services; and the visit frequencies. Pt. #6. SOC 2/28/24 – Lacked SN, Home Health Aide services; and the visit frequencies. Pt. #7. SOC 6/6/24 – Lacked SN, PT, and OT visit frequencies. 3. Home visits were conducted on the following Pts. on 12/16/24 and 12/17/24: Pt. #2. SOC 6/24/24. The folder lacked a consent form for the SOC conducted on 6/24/24, as required by the Agency. Pt. #3. SOC 8/2/24. The folder lacked a consent form for the SOC conducted on 8/2/24, as required by the Agency. 4. During interviews with the Administrator, and Clinical Manager on 12/18/24 from 2:00 PM to 4:00 PM, both confirmed the above findings.”

“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 a review of clinical records, Agency policy, and staff interviews, it was determined for 2 of 7 (Pts. #5 and 7) clinical records reviewed, the Agency failed to ensure PsOC included all the requirements. Findings include: 1.Pt. #5 was admitted for home health services on 11/19/24 with a diagnosis of but not limited to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Essential (Primary) Hypertension and Abnormal Weight Loss. The clinical record was reviewed on 12/17/24. The clinical record included documentation that Pt. #5 was discharged from an in-patient facility with a significant weight loss. The record also included documentation of high blood glucose results in the nursing progress notes. The POC effective 11/19/24 lacked parameters for vital signs, blood glucose and weight. 2. Pt. #7 was admitted for home health services on 6/6/24 with a diagnosis of but not limited to Gastrointestinal Hemorrhage, Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease or End Stage Renal Disease. The clinical record was reviewed on 12/18/24. The POC for the certification period of 6/6/24 to 8/4/24 lacked specific care interventions and Pt./caregiver education for dialysis treatment and care. 3. The Agency policy titled, “Care Planning and Coordination” was reviewed on 12/19/24 and required, “Policy: An individualized plan of care is developed by Agency licensed staff for each patient based upon an assessment that reflects the patient’s identified problems and needs…The plan of care includes at least the following information: Interventions to address the identified patient needs… 4. During an interview conducted with the Administrator and Clinical Manager on 12/19/24 at 2:00 PM, the Clinical Manager stated that the dialysis centers manage the dialysis access, but the visiting nurse also observes for signs and symptoms of bleeding and infection during their visit. During the same interview, both confirmed that the POC should include interventions to address Pt. needs that were identified. The above findings were also confirmed at the interview.”

“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 a review of clinical records, Agency policy and staff interviews, it was determined that for 4 of 7 (Pts. #1, 2, 3 and 4) clinical records reviewed, the Agency failed to ensure that care and services provided were according to Physician orders, and as indicated in the POC. 3. Pt. #3 was admitted to home health services on 8/2/24 with the diagnosis of Pressure Ulcer of Sacral. The clinical record was reviewed on 12/18/24. The clinical record included the PT evaluation dated 10/18/24, PT visit notes 1 to 2 times a week from 11/19/24 to 11/27/24, and the PT evaluation dated 11/29/24. As of 12/18/24, the record lacked a Physician order for the PT services provided from 10/18/24 to 11/29/24. 4. Pt. #4 was admitted to home health services on 10/2/24 with the diagnosis of Spinal Stenosis, Lumbar Region without Neurogenic Claudication. The clinical record was reviewed on 12/17/24. The clinical record included the POC for the certification period of 10/2/24 to 11/30/24 that required the ST to evaluate. The ST evaluation was conducted on 10/8/24, and required the ST to provide service “2wk1, 1wk2”. The record lacked a Physician order for the additional ST services provided on 10/29/24, 11/5/24 and 11/12/24. The POC effective 10/2/24 required the OT to evaluate. The OT evaluation was conducted on 10/10/24, and required the OT to provide service “1wk1, 2wk3”. The record lacked a second OT visit during the weeks of 10/20/24 to 10/26/24 and 10/27/24 to 11/2/24. The record lacked a Physician order for the additional OT services provided on 11/4/24 and 11/11/24. The POC effective 12/1/24 required the Home Health Aide to provide service “2wk9”. The record lacked documentation of any visits during the week of 12/1/24 to 12/7/24. 5. The Agency’s policy titled; “Confirmation of Physician Telephone/Verbal Orders” was reviewed on 12/19/24. The policy required, “…Agency provides care, treatment and/or services to patients according to a physician’s or licensed practitioner’s most recent order(s) or prescription(s)… Care, treatment and/or services are provided according to the most recent order/prescription…” 6. During staff interviews with the Administrator and Clinical Manager on 12/18/24 from 2:00 PM to 4:00 PM, both confirmed the Agency failed to ensure care and services were provided as ordered by the Physician or indicated in the POC. 2. Pt. #2 was admitted for home health services on 6/24/24 with the diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure, and Pressure Ulcer of the Left Buttock. The clinical record was reviewed on 12/17/24. The clinical record included the POC for the certification period of 10/22/24 to 12/10/24 that required the PT to evaluate. As of 12/17/24, the record lacked a PT evaluation on or after 10/22/24. Findings include: 1.Pt. #1 was admitted for home health services on 9/7/24 with the diagnosis of Idiopathic Gout of Left Knee. The clinical record was reviewed on 12/17/24. The Nursing Progress Note in the clinical record dated 12/7/24 included the documentation, “BS is high, SN administered glargine 30 u bid to left abd sc.” The clinical record lacked a Physician order for the medication administered by the SN.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on a review of the Agency’s Pt. admission folder, observation during home visits, clinical record review and staff interview, it was determined that for 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to provide information regarding the Clinical Manager and their contact information. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 12/16/24. The folder lacked information identifying the name and contact information of the Clinical Manager. 2. The following home visits were conducted on 12/16/24 and 12/17/24: Pt. #1. SOC 9/7/24. Pt. #2. SOC 6/24/24. Pt. #3. SOC 8/2/24. During the home visits, the Pt. admission folders were reviewed. The folders lacked the name and contact information of the Clinical Manager. 3. During an interview with the Administrator and Clinical Manager on 12/18/24 from 2:00 PM to 4:00 PM, both indicated the same admission folder is given to all Pts. and confirmed that the folder lacked the name and contact information of the Clinical Manager.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on a review of clinical records, Agency policies, and staff interviews, it was determined in 3 of 7 (Pts. #2, 1 and 7) clinical records reviewed, the Agency failed to ensure that documentation entered into the clinical records was complete and accurate. 2. Pt. #1 was admitted for home health services on 9/7/24 with the diagnosis of Idiopathic Gout of Left Knee and Pressure Ulcer of the Left Heel. The clinical record was reviewed on 12/17/24. The nursing progress note dated 9/21/24 included documentation that the measurements for the pressure ulcer on the left heel is 0 x 0 x 0. As of 12/7/24, there was no other documentation of a pressure ulcer on the left heel in the clinical record. During an interview with the Clinical Manager on 12/18/24, it was stated that the pressure ulcer had healed and that the POC had an inaccurate diagnosis of Pressure Ulcer of the Left Heel. 3. Pt. #7 was admitted for home health services on 6/6/24 with a diagnosis of but not limited to Gastrointestinal Hemorrhage and Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease or End Stage Renal Disease. The clinical record was reviewed on 12/18/24. The clinical record included the initial comprehensive assessment completed by the RN on 6/6/24. The assessment lacked an entry in Section O - O0100 Special Treatments, Procedures and Programs, indicating that Pt. #7 received dialysis treatments. 4. The Agency policy titled, “Clinical Documentation” was reviewed on 12/18/24 and required, “Special Instructions: Documentation of services ordered on the plan of care will be completed the day service is rendered...” 5. The Agency policy titled, “Pressure Ulcer Dressing Change” was reviewed on 12/19/24 and required, “Documentation Guidelines: 1. Document in the clinical record: a. Date and time of procedure...” 6. The Agency policy titled, “Wound Documentation Policy” was reviewed on 12/19/24 and required, “Responsibilities: Supervisors/Case Managers: Review documentation for completeness and accuracy...” 7. During staff interviews conducted with the Administrator and Clinical Manager on 12/18/24 from 2:00 to 4:00 PM, it was stated that the entries in the clinical records should be accurate and complete. During the same interviews, the above findings were confirmed. Findings include: 1. Pt. #2 was admitted for home health services on 6/24/24 with the diagnoses of the Left Buttock. The clinical records were reviewed on 12/17/24. The clinical record included the weekly “Nursing Progress Notes” from 10/28/24 to 12/16/24, with documentation that all visits were conducted between 1:00 PM to 3:15 PM. The “Wound Care Worksheet” visit notes for the same dates, completed by the same SN from 10/28/24 to 12/16/24 included the time of 8:21 AM for each “Wound Care Worksheet” visit note. Due to the conflicting times of the visit notes, it cannot be determined when the skilled nurse provided service. During an interview on 12/18/24 at 3:34 PM with the Administrator who verified that Pt. #2 received one visit per week from the SN from 10/28/24 to 12/16/24, and not two visits in one day. During the same interview, the Administrator was unable to verify the times of the weekly visits (AM or PM).”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on a review of clinical records, observation and interview during a home visit, Agency policy review, and staff interviews, it was determined that 2 of 7 (Pts. #3 and 7) clinical records reviewed, the Agency failed to ensure the medications listed in the clinical record were complete and accurate. 2. Pt. #7 was admitted for home health services on 6/6/24 with a diagnosis of but not limited to Gastrointestinal Hemorrhage, Hypertensive Chronic Kidney Disease with Stage 5 Chronic Kidney Disease or End Stage Renal Disease. The clinical record was reviewed on 12/18/24. The clinical record included the Nursing Progress Note dated 6/13/24 that included documentation, “Pt. has changed…medication regimen. Pt.’s carvedilol was discontinued, and Pt. has newly prescribed medication metoprolol 25 mg 1 tab daily…” Pt. #7’s medication profile was not updated to reflect these changes. 3. The Agency policy titled, “Medication Management -Patient Information” was reviewed on 12/19/24 and required, “Purpose: To create and maintain accurate medication history and current medication profile while the patient is receiving care, treatment and/or services from the Agency…Policy: The patient’s medications are reviewed and assessed during each skilled visit…” 4. During an interview was conducted with the Administrator and Clinical Manager on 12/18/24 from 2:00 to 4:00PM, both stated that a medication reconciliation should be conducted, and the medication profile should be updated to reflect the Pt.’s current medications. During the same interview the above findings were confirmed. Findings include: 1. Pt. #3 was admitted to home health services on 8/2/24 with the diagnosis of Pressure Ulcer of Sacral. The clinical record was reviewed on 12/18/24. The clinical record included the “Patient Medication Profile” that included “Metformin 1000 MG- 1 tablet PO 2x daily, Alfuzosin ER 10 mg tablet- 1 tablet PO 1x daily, Ozempic 0.5 mg subcutaneous (Pen injector) every 4 weeks”. A home visit was conducted on 12/17/24 with Employee #3. During the home visit observed: Metformin 500 MG 1 tablet taken by mouth 2 times daily, Tamsulosin Hydrochloride capsules 0.4 MG, One A Day Men’s 50+ Multivitamin 1 tablet daily by mouth, Atorvastatin 40 MG Tablet take 1 tablet by month every day, Albuterol Sulfate Inhalation Aerosol 90 MCG per actuation 2 puffs as needed every 4 hours as needed, and Melatonin 3 MG by mouth nightly. An interview was conducted with Pt. #3’s primary caregiver that stated: The Physician decreased the Metformin from 1000 MG to 500 MG in October 2023; Tamsulosin Hydrochloride and Alfuzosin ER are similar medications, so the Physician discontinued the Alfuzosin ER, and restarted Tamsulosin in May 2024; Pt. #3 began taking One A Day Men’s 50+ Multivitamin “at least for the past 6 months”; the Physician prescribed Atorvastatin “for more than a year”, and Albuterol Sulfate “last April (2024)”; the Pt. began taking “Melatonin for at least a year, the doctor said it was ok with the other medicines he’s taking... and the doctor increased the Ozempic from 0.5 mg to 1 mg in October (2024)”. During an interview with the Administrator and the Clinical Manager on 12/18/24 at 2:40 PM, the Clinical Manager/RN Case Manager stated, “I need to update the Medication Profile”.”