Evangel Home Health Services, Inc.

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on review of the Agency’s Emergency Preparedness plan and staff interviews, it was determined the Agency failed to ensure that staff receive Emergency Preparedness training every 2 years. This has the potential to affect all patients in the Agency. Findings include: 1. The Emergency Preparedness Plan was reviewed on 07/30/24. The Plan lacked documentation that staff received Emergency Preparedness training every 2 years from 2021 to 2024. 2. During an Interview with the Administrator, Quality Assurance Coordinator/Alternate Administrator and Director of Nursing on 07/31/24 at 11:30 AM, 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 Error Summary report and Staff interview, it was determined in 161 of 343 reports submitted for the last 12 months, the Agency failed to submit all timely reports, resulting in a warning. Findings include: 1. The Error Summary report for 04/2023 to 03/2024, was reviewed on 07/31/24 at 9:30 AM. The report included error # -3330 for 161 of 343 late submissions, 46.94% of the OASIS reports submitted, were more than 30 days after the M0090. 2. During an interview with the Administrator, Quality Assurance Coordinator/Alternate Administrator and Director of Nursing on 7/31/24 at 11:30 AM, the Administrator confirmed that the error occurred.”

“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 clinical records review and staff interview, it was determined in 3 of 7 (Pts. # 3, 4 and 7) clinical records reviewed, the patient care was not provided as ordered by the Physician in the plan of care. 3. Pt. # 7 was admitted for Home Health Services on 12/06/23 with the diagnosis of Type 2 Diabetes Mellitus without Complication. The clinical record reviewed on 07/30/24. The record included a referral from the physician dated 11/30/23 with an order that required, “Need PT, OT and HHA” As of 7/30/24, the record lacked documentation of an HHA visit. 4. During an interview with the Administrator, Quality Assurance Coordinator/Alternate Administrator on 7/30/24 at 2:00 PM, it was stated that all physician orders and the POC should be followed. During the same interview, the above findings were confirmed. Findings include: 1. Pt. #3 was admitted to Home Health Services on 02/24/24 with the diagnosis of Pressure Induced deep tissue damage of Left Buttocks, History of COVID 19 and Chronic Combined Systolic and Diastole Heart Failure. The clinical record was reviewed on 07/30/24. The clinical record contained a POC dated 06/23/24, that required SN to assess the patient’s vital signs and weight, 1 time a week for 9 weeks and notify the physician of significant changes. The SN assessed the blood pressure on 06/25/24 as 140/76 and on 07/04/24 as 98/66. The physician was not notified of the significant change in blood pressure. The SN notes also lacked weight assessment for the entire certification period beginning 06/23/24. 2. Pt. #4 was admitted to Home Health Services on 03/05/24 with the diagnosis of Bilateral Primary Osteoarthritis and Heart Failure Unspecified. The clinical record was reviewed on 07/30/24. The clinical record contained a POC dated 07/03/24, that required SN to assess the patient’s weight, 1 time a week for 9 weeks. The SN failed to perform the weight assessment for the entire certification period beginning 07/03/24.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on a review of clinical records, and staff interview, it was determined that for 3 of 7 (Pts. #3, 5 and 7) clinical record reviewed, the Agency failed to ensure forms and records were complete and accurate. Findings include: 1. The following clinical records were reviewed on 7/30/24 at 9:15 AM to 4:00 PM: Pt. #3. SOC: 02/24/24 Pt. #5. SOC: 02/23/24 Pt. #7. SOC: 12/16/23 On 07/31/24, the form “Consent for Home Care Services and Agreement” which is obtained at the SOC and contained consent for treatment, liability notice, acknowledgement for rights and responsibilities, was not incorporated in the above-mentioned clinical records. 2. During an interview with the Administrator, Quality Assurance Coordinator/Alternate Administrator and Director of Nursing 07/31/24 at 9:30 AM and 11:30 AM, it was stated that all areas in the records should be filled out completely and accurately and should be incorporated in the clinical records. During the same interview, the above findings were confirmed”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on clinical record review, and staff interviews, it was determined that for 1 of 1 (Pt. #6) Pt. wherein MSW services were provided, the Agency failed to ensure that concerns were communicated/coordinated within the healthcare team to ensure Pt. needs were identified and addressed. 2. During the interview with the Administrator, Quality Assurance Coordinator/Alternate Administrator, and the Director of Nursing, on 07/31/24 at 11:30 am, the Director of Nursing stated that the MSW documented concerns on their assessment note, but it was not coordinated with the RN. In the same interview, the above findings were confirmed. Findings include: 1. Pt. #6 was admitted for Home Health Services on 06/27/23 with the diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 07/30/24 at 3:00 PM. The MSW assessment note dated 07/01/23 included documentation that Pt. #6 was referred to the Illinois Department of Human Services to request for increase for food stamp benefits. The clinical record lacked documentation of the Agency’s follow up of the referral request and Pt. follow up. The MSW note also included the documentation, “Assessment/Interventions…Pt. reports…no longer taking meds… (Pt.) reports is trying natural herbs and remedies.” The clinical record lacked documentation that there was coordination between the MSW and RN related to the changes in medications verbalized by the Pt. to the MSW.”

“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 review of clinical records and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed. Findings include: 1. Pt. #6 was admitted to Home Health Services on 6/27/23 with a diagnosis of Bilateral Primary Osteoarthritis of Knee. The record contained a Discharge comprehensive assessment dated 12/23/23, indicating that Pt. #6 was discharged from the Agency. On 7/31/24, the record lacked documentation that a copy of Pt. #6’s discharge summary was sent to the Physician. 2. Pt. #7 was admitted to Home Health Services on 12/06/23 with a diagnosis of Type 2 Diabetes Mellitus without complications. The record contained a Discharge comprehensive assessment dated 05/28/24, indicating that Pt. #7 was discharged from the Agency. On 7/31/24, the record lacked documentation that a copy of Pt. #7’s discharge summary was sent to the Physician. 3. During an interview with the Administrator, Quality Assurance Coordinator/Alternate Administrator and Director of Nursing on 07/31/24 at 11:30 AM, the above findings were confirmed.”