Focus 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 interviews, it was determined that in 92 of 658 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Finding include: 1. The Error Summary report for 4/2023 to 3/2024, was reviewed on 7/11/24. The report included error # -3330 for 92 of 658 late submissions, which was 13.98% of the OASIS reports submitted late, more than 30 days after the M0090. 2. During an interview with the Administrator and Alternate Agency Supervisor on 7/11/24 at 11:00 AM, the administrative team confirmed that the error occurred.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the Agency failed to ensure an RN performed the initial assessment within 48 hours of the Physician referral for Home Health Care services. This was found in 2 of 7 (Pts. #4 and 6) clinical records reviewed. 1. Pt. #4 was admitted to Home Health Services on 4/29/24 with diagnosis of Cellulitis of Left Lower Limb. The clinical record was reviewed on 7/9/24. The Face-to Face form signed by the A/GNP (Adult Gerontology Nurse Practitioner) on 4/25/24 and received by Agency on 4/26/24 required: “Skilled Nursing wound care BLE (Bilateral Leg Extremity) and PT/OT evaluation and treatment.” The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 7/11/24, the record lacked documentation the Agency initiated service within the required time frame. 2. Pt. #2 was admitted to Home Health Services on 7/20/23 with the diagnosis of Bilateral Primary Osteoarthritis of Hip. The clinical record was reviewed on 7/9/24. The Face-to Face form signed by the Physician on 6/28/23 and received by Agency on 7/17/23 required: “SN services, PT to improve patient’s gait for safety and mobility, MSW evaluation for homemaker and CNA/HHA for bathing. The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 7/11/24, the record lacked documentation the Agency initiated service within the required time frame. 3. During an interview with the Agency Supervisor and Alternate Agency Supervisor, on 7/10/24 at 12:30 PM, the administrative team confirmed the initial assessment visits were conducted, after 48 hours of the Face to Face or referral date.”

“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 clinical record review, policy review and staff interviews, it was determined for 1 of 7 (Pt. #5) Pts., the Agency failed to ensure Plans of Care included all the requirements. Findings include: 1. Pt. #5 was admitted for home health services on 4/25/24 with the primary diagnosis of Pressure Ulcer of the Right Buttock. The clinical record was reviewed on 7/10/24. The SOC comprehensive assessment and all the SN notes contained documentation that Pt. #5 uses a urinary catheter related to the diagnosis of urinary retention. Pt. #5’s Plans of Care for the certification periods of 4/25/24 to 6/23/24 and 6/24/24 to 8/22/24 lacked documentation of the use of a urethral catheter and lacked the procedure, the equipment, and supplies used for its care. 2. The policy titled “Care Plans” was reviewed on 7/10/24 and required: “Policy: Each client will have a care plan on file that addresses their identified needs and the (Agency’s) plan to respond to those needs…Purpose: …To provide updated, coordinated document that reflects the current home care services.” 3. During an interview conducted with the Agency Supervisor and the Alternate Agency Supervisor on 7/10/24 at 11:00 AM, the above finding was confirmed.”

“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 clinical record review, policy review and staff interviews, it was determined for 1 of 3 (Pt. #5) clinical records reviewed receiving wound care, the Agency failed to ensure care and/or services were provided in conformance with the orders of the physician and as indicated in the Plan of Care. Findings include: 1. Pt. #5 was admitted to home health services on 4/25/24 with the primary diagnosis of Pressure Ulcer of The Right Buttock Stage 2 and other diagnosis of, but not limited to, Pressure Ulcer of The Left Buttock Stage 2, Hypertensive Heart Disease with Heart Failure and Encounter for Fitting and Adjustment of Urinary Device. The clinical record was reviewed on 7/10/24. The face-to-face document dated 4/25/24 which contained physician orders, included the following documentation: “Urinary Retention: Continue with monthly changes 14 French.” The SN notes dated 4/29/24, 5/27/24, 6/3/24 and 7/3/24 contained documentation that the urinary catheter was changed by the SN using a French 16 size urinary catheter. The clinical record lacked documentation of a physician order indicating a change in the size of Pt. #5’s urinary catheter. The referral document dated 4/18/24 also included the following: “Please review for PT/OT...” The clinical record lacked documentation of an OT evaluation or visit. Pt. #5’s Plan of Care effective 6/24/25 required: “SN to measure wound once a week and report to MD wound progress as needed.” The SOC comprehensive assessment and SN notes from 5/6/24 to 7/3/24 lacked documentation of wound measurements. The same Plan of Care required: “SN to monitor and report weight gain of 2 pound in a day or 5 pounds in 7 days. “ The SOC comprehensive assessment and SN notes from 5/6/24 to 7/3/24 lacked documentation of the monitoring of Pt. #5’s weight. 2. The policy titled, “Wound Care and Management Policy” was reviewed on 7/10/24 and required, “2. Skilled Nurse will document wound assessment in the Skilled Nursing visit at least once a week…Documentation may include the following: …Measurement (Length, Width, Depth).” 3. The policy titled, “Physician Orders” was reviewed on 7/10/24 and required. “All medications, treatments, and services provided to clients must be ordered by a physician or authorized practitioner…All medications and treatments that are part of the client’s plan of care must be ordered by the physician.” 4. During an interview conducted with the Agency Supervisor and the Alternate Agency Supervisor on 7/10/24 at 11:00 AM, it was stated that physician orders and orders on the care plan should be followed. During the same interview, the above findings were confirmed.”