Good Shepherd Healthcare, LLC

“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 1 of 27 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 8/2023 to 7/2024, was reviewed on 11/13/24. The report included error # -3330 for 1 of 27 late submissions, which was 3.70 % of the OASIS reports submitted late, more than 30 days after the M0090. 2. During an interview with the Administrator Assistant on 11/14/24 at 9:15 AM, the Administrator Assistant confirmed that the error occurred.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. 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 reviews, and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./patient’s representative information regarding the Administrator. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 11/12/24 at 10:50 AM. The folder lacked the Administrator’s name, address, and phone number to file a complaint and/or grievance. 2. The following home visits were conducted on 11/12/24: Pt. #1. SOC 9/27/24. Pt. #2. SOC 10/17/24. Pt. #3. SOC 10/12/24. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Administrator. 3. The following clinical records were reviewed on 11/12/24 and 11/13/24: Pt. #1. SOC 9/27/24. Pt. #2. SOC 10/17/24. Pt. #3. SOC 10/12/24. Pt. #4. SOC9/25/24. Pt. #5. SOC 7/19/24. Pt. #6. SOC 7/23/24. Pt. #7. SOC 7/10/24. The clinical records lacked documentation that the Pt./patient’s representative was provided the name and contact of the Administrator to file a complaint or grievance. 4. During the entrance interview on 11/12/24 at 9:30 AM with the Assistant Administrator, Agency Supervisor, and the QAPI Coordinator; the Assistant Administrator stated the Administrator was hired 2 years ago. 5. During staff interviews with the Agency Supervisor/Director of Nursing, and the QAPI Coordinator on 11/13/24 at 11:05 AM and 2:15 PM, both confirmed the Agency failed to provide the Pt./patient’s representative information regarding the Administrator.”

“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 a review of clinical records, and staff interviews, it was determined in 6 of 7 (Pts. #1, 4, 6, 2, 3, and 7) clinical records reviewed, the Agency failed to ensure a referral was obtained to initiate service or that the initial assessment visit was done within 48 hours of receipt of the referral. 4. Pt. #2 was admitted to home health services on 10/17/24 with diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 11/13/24. The Face-to Face form signed by the APRN (Advanced Practice Registered Nurse) on 10/12/24 and received by the Agency on 10/12/24 that required: “Skilled Nursing Care and Physical Therapy for evaluation/assessment of rehab needs.” The record lacked a physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 11/13/24, the record lacked documentation the Agency initiated service within the required time frame. 5. Pt. #3 was admitted to home health services on 10/18/24 with diagnosis of Hemiplegia following Cerebral Infarction affecting right dominant side. The clinical record was reviewed on 11/13/24. The Face-to Face form signed by the Physician on 10/3/24 and received by the Agency on 10/3/24 the required: “Home Health Skilled Nursing Services.” The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 11/13/24, the record lacked documentation the Agency initiated service within the required time frame. 6. Pt. #7 was admitted to home health services on 7/10/24 with diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 11/13/24. The Face-to Face form signed by the Physician on 6/16/24 and received by the Agency on 6/16/24 that required: “Skilled Nursing Care and Physical Therapy for evaluation/assessment of rehab needs.” The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 11/13/24, the record lacked documentation the Agency initiated service within the required time frame. 7. During an interview with the Assistant Administrator, Agency Supervisor/ Director of Nursing, and QAPI Coordinator on 11/13/24 at 11:05 AM and 2:30 PM; the administrative team confirmed the initial assessment was not done within the time frame requirement. Findings include: 1. Pt. #1 was admitted to home health services on 9/27/24 with the diagnosis of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. The clinical record was reviewed on 11/12/24. The record contained a referral that was faxed from the physician’s office to the Agency on “9/16/2024”. The “OASIS-E Start of Care” assessment form was completed by the SN on “9/27/2024. As of 11/12/24, the record lacked documentation of an inpatient facility stay, physician ordered SOC date, and that the Agency initiated service within 48 hours after the referral was received. 2. Pt. #4 was admitted to home health services on 9/25/24 with the diagnosis of Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 11/13/24. The record contained a referral that was faxed from the physician’s office to the Agency on “9/16/2024”. The “OASIS-E Start of Care” assessment form was completed by the SN on “09/25/2024”. As of 11/13/24, the record lacked documentation of an inpatient facility stay, physician ordered SOC date, and that the Agency initiated service within 48 hours after the referral was received. 3. Pt. #6 was admitted to home health services on 7/23/24 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 11/12/24. The record contained a referral that was faxed from the physician’s office to the Agency on “06/26/2024”. The OASIS-E Start of Care” assessment form was completed by the SN on “07/23/2024”. As of 11/12/24, the record lacked documentation of an inpatient facility stay, physician ordered SOC date, and that the Agency initiated service within 48 hours after the referral was received.”

“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 reviews, and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./patient’s representative information regarding the Agency Supervisor/Director of Nursing. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 11/12/24. The folder lacked the name and information to contact the Agency Supervisor/Director of Nursing. 2. The following home visits were conducted on 11/12/24: Pt. #1. SOC 9/27/24. Pt. #2. SOC 10/17/24. Pt. #3. SOC 10/12/24. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Agency Supervisor/Director of Nursing. 3. The following clinical records were reviewed on 11/12/24 and 11/13/24: Pt. #1. SOC 9/27/24. Pt. #2. SOC 10/17/24. Pt. #3. SOC 10/12/24. Pt. #4. SOC9/25/24. Pt. #5. SOC 7/19/24. Pt. #6. SOC 7/23/24. Pt. #7. SOC 7/10/24. The clinical records lacked documentation that the Pt./patient’s representative was provided the name and contact of the Agency Supervisor/Director of Nursing. 4. During the entrance interview on 11/12/24 at 9:30 AM with the Assistant Administrator, Agency Supervisor, and the QAPI Coordinator; the Assistant Administrator stated the Agency Supervisor/Director of Nursing was hired 2 years ago. 5. During staff interviews with the Agency Supervisor/Director of Nursing, and the QAPI Coordinator on 11/13/24 at 11:05 AM and 2:15 PM, both confirmed the Agency failed to provide the Pt./patient’s representative information regarding the Agency Supervisor/Director of Nursing.”