Carefirst Rehab LLC

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on record review and interview the agency failed to ensure home health aides had written patient care instructions prepared by a registered nurse or other appropriate skilled professional for 1 of 3 patients with home health aides, records reviewed (Patient #13). Findings include: 1. A review of a policy titled “Home Health Aide Care Plan” indicated but was not limited to: “Each patient receiving service from a Home Health Aide is to have a care plan developed by the coordinating nurse at the onset of service. It is to be updated as needed and at least every 60 days for patients receiving skilled services and at least every 6 months for patients receiving only unskilled services…” 2. The Clinical Record for Patient #13 failed to evidence an updated Home Health Aide Care Plan for the Certification Period 10/22/2024-12/20/2024. 3. During an interview on 12/09/2024 at 1:55 PM, the Alternate Clinical Supervisor indicated the clinical record for Patient #13 did not include a Home Health Aide Care Plan for the current certification period. She indicated she would update and initiate the Care Plan immediately and was unsure why staff had not created a Care Plan for the current certification period. 410 IAC 17-13-2(a)”

“Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure patients were advised in writing of the charges for services the individual may have to pay before care is initiated for 8 of 17 patient records reviewed (Patient #1, #4, #5, #6, #7, #13, #15, #17). Findings include: 1. Review of a policy titled “Charge Determination” indicated but was not limited to: “The patient’s authorization to bill for services shall be initiated and presented to the responsible party for signature at the time of the initial visit. The agreement shall specify: Patient name, Service address, Responsible party, Charges for services (may be on separate form), Assignment of benefits, Responsibility and terms for payment … Patients with financial liability shall be notified in writing at the time of admission and before the onset of services of the Agency’s charges…” 2. The Clinical Record for Patient #1, SOC 08/26/2022, failed to evidence a completed document titled “Consent for Treatment and Financial Agreement,” which details the cost of services provided and the expected amount due by the patient after insurance payment. 3. The Clinical Record for Patient #4, SOC 12/23/2023, failed to evidence a completed document titled “Consent for Treatment and Financial Agreement,” which details the cost of services to be provided and expected patient responsibility after insurance payment. 4. The Clinical Record for Patient #5, SOC 08/12/2024, failed to evidence a completed document titled “Consent for Treatment and Financial Agreement,” which details the cost of services to be provided and expected patient responsibility after insurance payment. 5. The Clinical Record for Patient #6, SOC 11/21/2024, failed to evidence a completed document titled “Consent for Treatment and Financial Agreement” which details the cost of services to be provided and expected patient responsibility after insurance payment. 6. The Clinical Record for Patient #7, SOC 10/29/2024, failed to evidence a completed document titled “Consent for Treatment and Financial Agreement” for the cost of services to be provided and expected patient responsibility after insurance payment. 7. The Clinical Record for Patient #13, SOC 08/23/2024, failed to evidence a completed document titled “Consent for Treatment and Financial Agreement” which details the cost of services to be provided and expected patient responsibility after insurance payment. 8. The Clinical Record for Patient #15, SOC 08/28/2024, failed to evidence a completed document titled “Consent for Treatment and Financial Agreement” which details the cost of services to be provided and expected patient responsibility after insurance payment. 9. The Clinical Record for Patient #16, SOC 11/07/2024, failed to evidence a completed document titled “Consent for Treatment and Financial Agreement” which details the cost of services to be provided and expected patient responsibility after insurance payment. 10. The Clinical Record for Patient #17, SOC 09/13/2024, failed to evidence a completed document titled “Consent for Treatment and Financial Agreement” which details the cost of services to be provided and expected patient responsibility after insurance payment. 11. During an interview on 12/10/2024 at 1:22 PM, the Alternate Clinical Supervisor and Administrator indicated at the initial/SOC visit, agency staff is expected to fill out costs or indicate ‘not applicable’ as appropriate and completely fill out the consent for treatment and financial agreement form provided for patient/power of attorney signature.”

“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 record review and interview the agency failed to ensure the initial assessment visit was completed within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician ordered start of care date for 8 of 11 skilled nursing records reviewed (Patients #3, #5, #7, #8, #13, #14, #15, and #17). Findings include: 1. Review of a policy titled “Referral and acceptance of Patients/Clients” indicated but was not limited to: “Upon receipt of a referral, an evaluation by a RN and/or appropriate therapist will be made to determine that the care can be adequately and safely performed at home, to assess the patient/client care needs, and to ensure that the patient/client meets the admission criteria. Patients/clients will be evaluated by a nurse or appropriate staff member within 48 hours of referral or discharge from a facility whenever possible.” 2. The clinical record for Patient #3 included a referral received on 07/17/2023 with an initial nursing assessment and SOC OASIS Comprehensive Assessment admission completed on 07/21/2023 for the POC certification period of 07/21/2023 to 09/18/2023. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and an initial assessment of the patient for admission into the agency. 3. The clinical record for Patient #5 included a referral received on 07/23/2024 that had an initial nursing assessment and SOC OASIS Comprehensive Assessment admission completed on 08/12/2024 for the POC certification period of 08/12/2024 to 10/10/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and admission into the agency with the initial nursing assessment. 4. The clinical record for Patient #7 included a referral received on 10/17/2024 that had an initial nursing assessment and SOC OASIS Comprehensive Assessment admission completed on 10/29/2024 for the POC certification period of 10/29/2024 to 12/27/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and admission into the agency with the initial nursing assessment. 5. The clinical record for Patient #8 included a referral received on 09/17/2024 that had an initial nursing assessment and SOC OASIS Comprehensive Assessment admission completed on 09/24/2024 for the POC certification period of 09/24/24 to 11/22/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and an initial assessment of the patient for admission into the agency. 6. The clinical record for Patient #13 included a referral received on 08/07/2024 with an initial nursing assessment and SOC OASIS Comprehensive Assessment admission completed on 08/23/2024 for the POC certification period of 08/23/2024 to 10/21/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and an initial assessment of the patient for admission into the agency. 7. The clinical record for Patient #14 included a referral received on 9/22/2024 that had an initial nursing assessment and SOC OASIS Comprehensive Assessment admission completed on 9/25/2024 for the POC certification period of 9/25/2024 to 11/3/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and an initial assessment of the patient for admission into the agency. 8. The clinical record for Patient #15 included a referral received on 08/23/2024 that had an initial nursing assessment and SOC OASIS Comprehensive Assessment admission completed on 08/25/2024 for the POC certification period of 08/28/2024 to 10/26/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and an initial assessment of the patient for admission into the agency. 9. The clinical record for Patient #17 included a referral received on 08/07/2024 that had an initial nursing assessment and SOC OASIS Comprehensive Assessment admission completed on 09/13/2024 for the POC certification period of 09/13/2024 to 11/11/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and an initial assessment of the patient for admission into the agency. 10. During an interview on 12/05/2024 at 1:30 PM, the Administrator, Alternate Administrator, and Alternate Director of Nursing (Alternate Clinical Supervisor) indicated that Medicare patients most often meet the 48-hour window required for compliance between receipt of referral and completion of the initial assessment/SOC OASIS comprehensive assessment for admission. However, Medicaid and private insurance approval for requested services has not been received in a timely manner, requiring the agency to write a new order for SOC once received and sent to the ordering physician for signature. The provider then completed admission OASIS/initial assessments within 48 hours of receipt of the new order. 410 IAC 17-14-1(a)(1)(A)”

“Skilled professional performs assessment CFR(s): 484.55(a)(2) When rehabilitation therapy service (speech language pathology, physical therapy, or occupational therapy) is the only service ordered by the physician or allowed practitioner who is responsible for the home health plan of care, the initial assessment visit may be made by the appropriate rehabilitation skilled professional. For Medicare patients, an occupational therapist may complete the initial assessment when occupational therapy is ordered with another qualifying rehabilitation therapy service (speech-language pathology or physical therapy) that establishes program eligibility. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure the initial assessment visit was completed within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician ordered start of care date for 2 of 6 therapy only records reviewed (Patients #4 and #9). Findings include: 1. Review of a policy titled “Referral and acceptance of Patients/Clients” indicated but was not limited to: “Upon receipt of a referral, an evaluation by a RN and/or appropriate therapist will be made to determine that the care can be adequately and safely performed at home, to assess the patient/client care needs, and to ensure that the patient/client meets the admission criteria. Patients/clients will be evaluated by a nurse or appropriate staff member within 48 hours of referral or discharge from a facility whenever possible.” 2. The clinical record for Patient #4 included a referral received on 11/16/2023, which included an initial therapy assessment and SOC OASIS Comprehensive Assessment admission completed on 12/8/2023 for the POC certification period of 4/6/2024 to 6/4/2024. The review failed to evidence any documentation, MD orders, or communication notes in the record that indicated a reason for the delay between referral receipt and an initial assessment of the patient for admission into the agency. 3. The clinical record for Patient #9 included a referral received on 10/23/2024 that had an initial therapy assessment and SOC OASIS Comprehensive Assessment admission completed on 11/5/2024 for the POC certification period of 11/5/2024 to 1/3/2025. The review failed to evidence any documentation, MD orders, or communication notes in the record to indicate a reason for the delay between referral receipt and an initial assessment of the patient for admission into the agency. 4. During an interview on 12/5/2024 at 1:30 PM, the Administrator, Alternate Administrator, and Alternate Director of Nursing (Alternate Clinical Supervisor) indicated that Medicare patients most often meet the 48-hour window required for compliance between receipt of referral and completion of the initial assessment/SOC OASIS comprehensive assessment for admission. However, Medicaid and private insurance approval for requested services has not been received promptly, requiring the agency to write a new order for SOC once received and sent to the ordering physician for signature. The provider then completed admission OASIS/initial assessments within 48 hours of receipt of the new order. 410 IAC 17-14-1(b)(3)(C)”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure an update of the comprehensive assessment was completed within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician ordered resumption date for 1 of 5 discharged patient records reviewed (Patient #5). Findings include: A review of a policy titled “Referral and acceptance of Patients/Clients” indicated but was not limited to: “Upon receipt of a referral, an evaluation by a RN and/or appropriate therapist will be made to determine that the care can be adequately and safely performed at home, to assess the patient/client care needs, and to ensure that the patient/client meets the admission criteria. Patients/clients will be evaluated by a nurse or appropriate staff member within 48 hours of referral or discharge from a facility whenever possible.” The Clinical Record for Patient #5, Certification Period 08/12/2024 - 10/10/2024, evidenced the patient was discharged from an inpatient hospital stay on 08/21/2024 and failed to evidence an update of the comprehensive assessment/ROC until 08/24/2024. During an interview on 12/05/2024 at 3:44 PM, the Alternate Clinical Supervisor stated that the staff did not complete the ROC for Patient 5 within 48 hours of their discharge from the hospital. She stated the agency’s goal was to meet that timeframe, but she was unsure why the staff did not complete it.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview the agency failed to ensure a registered nurse completed a supervisory assessment of the aide services being provided no less frequently than every 14 days for 1 of 3 patients with home health aides, records reviewed (Patient #15). Findings include: 1. Review of a policy titled “Carefirst Rehab Home Health Aide Supervisory Visit Policy” indicated but was not limited to: “Supervisory visits will occur at least every 14 days for each HHA, or more frequently if required by the patient’s condition…Supervisory visit notes will be documented in the patient’s medical record at time of visit…” 2. The Clinical Record for Patient #15, Certification Period 10/27/2024 - 12/25/2024, was reviewed on 12/9/2024 and evidenced a supervisory visit performed by RN 2 on 11/18/2024. The record failed to evidence any further supervisory visits after 11/18/2024. 3. During an interview on 12/09/2024 at 4:31 PM, the Alternate Clinical Supervisor indicated the clinical record for Patient #15 did not include documentation of an aide supervisory visit completed past 11/18/2024. She indicated that after speaking with RN 2, she discovered that the staff completed the supervisory visit on 12/2/2024, but the staff did not complete the documentation at the time of the visit. The Alternate Clinical Supervisor indicated that agency policy required staff to complete documentation of supervisory visits at the time of the visit.”