Saline County Health Department

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review, and staff interview, the home health agency failed to measure, analyze and tract quality indicators and adverse events as defined in their policy. This failure placed all patients on services with the home health agency at risk for unmet needs and adverse outcomes. Findings Include: Review of agency policy titled, “QAPI PLANNING,” dated 08/18/22, showed the agency planned to “collect, track, and analyze the following indicators: clinical outcomes, OASIS outcomes, hospital readmissions rates, emergency department visit rates, HHCAHPS survey results, complaints, infections, medication errors, falls, missed visits, and timely initiation of care.” Review of all agency QAPI data provided lacked evidence of any data tracked or analyzed for the above defined indicators for the years of 2023, 2024 or current year of 2025. During an interview on 08/14/25 at 2:45 PM, when asked to see the analyze of the QAPI program indicators, the agency Administrator, Staff A, stated, “I’ve given you everything, it is what it is.” She confirmed the above findings.”

“Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient’s rights and responsibilities under this rule and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This Element is not met as evidenced by: Based on review of agency documents, home observation, and staff interview, the agency failed to provide written notice of the Home Health Agency’s (HHA) transfer and discharge policies to 7 (Patient 1, 2, 3, 4, 5, 6, and 7) of 7 sample patients. This failed practice had the potential to place all patients on service at risk for unmet needs and the lack of understanding of agency’s services. Findings Include: Review of documentation (admission packet) provided to the patients, by the agency during the Initial Assessment and Start of Care, failed to show documented evidence of information regarding the HHA’s transfer or discharge policies. On 08/14/25 during three home observation visits, all paperwork (admission packet information) was reviewed for the HHA’s transfer and discharge policies. No written information regarding the HHA’s policies for transfers or discharges were found. During an interview on 08/14/25 at 3:50 PM, agency Staff A, Administrator, confirmed the above findings of not providing the patients with the HHA’s policies for transfer and discharge. She stated that she was unaware these policies were to be given to the patients.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review, and staff interview, the Home Health Agency (HHA) failed to provide patients with written notice, in advance of reducing or terminating a service for 1 (Patient 7) of 7 sampled patients. This practice failed to ensure the patient was made aware of his/her right to the expedited determination process and the ability to dispute the termination of services. Findings Include: Review of Patient 1’s clinical record showed the Home Health Certification and Plan of Care with a Start of Care date of 04/10/25. Review of Skilled Nurse visit notes showed a discharge visit was made on 08/07/25. During the Skilled Nurse visit on 08/07/25 the Registered Nurse had the patient sign the CMS form 10123 “Notice of Medicare Non-Coverage” (NOMNC) which explained the right to the expedited determination process and the ability to dispute the termination of Skilled Nursing services. The agency did not provide the required 48-hour notice before discharging the patient from services. During an interview on 08/14/25 at 1:15 PM, Staff A, Administrator, confirmed the above findings of the agency not providing the Notice of Medicare Non-Coverage (NOMNC) to the patients prior to discharge in the required timeframe and with the written instructions explaining the expedited determination process.”

“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 interview and record review, it was determined the home health agency (HHA) failed to ensure the completion of supervisory visits for 4 (Patient 2, 4, 5, 6) of 7 sample patients. This failure has the potential for patients to not receive the appropriate services and delay the patient’s progress toward meeting established goals. Findings Include: Review of Patient 2’s Plan of Care (POC) for the certification period dated 06/03/25-08/01/25, showed there was an order for home health aide services for two times per week for nine weeks. Review of Registered Nurse (RN) notes showed aide supervisory visit to have been made on 06/26/25, and 07/10/25. The next required aide supervisory visit would then be due on or before 07/24/25 however, the next documented aide supervisory visit was on 07/31/25, which was seven days late. Review of Patient 4’s Plan of Care (POC) with a Start of Care (SOC) dated 06/30/25 showed there was an order for home health aide services for two times per week for nine weeks. Review of aide clinical notes showed the home health aide services began on 06/30/25. Review of Registered Nurse (RN) notes dated 06/30/25, 07/15/25, 07/17/25, 07/21/25, 07/31/25, and 08/07/25 lacked documented evidence showing aide supervisory visits had been made as required. Review of Patient 5’s Plan of Care (POC) with a Start of Care (SOC) dated 04/15/25 showed there was an order for home health aide services for two times per week for nine weeks. Review of aide clinical notes showed the home health aide service began on 04/17/25 and continued for two times per week until 05/15/25. The Registered Nurse (RN) only made the SOC visit on 04/15/25 and the patient was seen by both Physical Therapy (PT) and Speech Therapy (ST) during the timeframe between 05/01/25 through 06/15/25. There was no documented evidence in the clinical record of any aide supervision by either the PT or the ST during the service episode of 04/15/25 - 06/13/25. Review of Patient 6’s Plan of Care for certification period dated (05/21/25-07/19/25) showed there was an order for home health aide services for one time per week for nine weeks. The previous certification period (03/22/25-05/20/25), showed home health aide services were provided and the most recent aide supervisory visit to be on 05/20/25 by the Registered Nurse (RN) during the recertification visit. The next required aide supervisory visit would then be due on or before 06/03/25 however, the next documented aide supervisory visit was on 06/11/25, which was eight days late. The next required aide supervisory visit would then be due on or before 06/25/25 however, the supervisory visit was not made on 06/25/25 or thereafter due to patient’s transfer to an in-patient facility for elective surgery on 06/27/25. During an interview on 08/13/25 at 3:55 PM, Staff A, Home Health Coordinator/ Administrator confirmed the above finding of home health aide supervisory visits not being made within the required fourteen days.”

“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 record review, and staff interview the Home Health Agency (HHA) skilled staff failed to ensure that all Comprehensive Assessment including OASIS and clinical notes were performed and maintained in the clinical record for 5 (Patient 1, 4, 5, 6, and 7) of 7 sample patients. The agency’s failure to ensure all Comprehensive Assessment/OASIS, and clinical notes were maintained in the clinical record placed all patients currently on service, at risk for unmet needs, care and services. Findings Include: Patient 1 Review of Patient 1’s clinical record showed a Start of Care date of 05/07/25. Review of clinical notes showed there was a recertification visit made on 07/01/25 by the Registered Nurse however, review of the note showed all areas to be blank or incomplete. Review of Patient 1’s clinical record also showed orders for Physical Therapy to evaluate and treat beginning on 05/07/25, however, at the time of survey there were no Physical Therapy notes in the patient’s record. Patient 4 Review of Patient 4’s clinical record showed a Start of Care date of 06/30/25 with orders for Physical Therapy one time for one week, two times for two weeks and then one time for one week. There were no Physical Therapy visit notes found in the EMR (Electronic Medical Record). The Physical Therapy evaluation was performed on 07/01/25 and all other visits followed as ordered until Physical Therapy services were discharged on 07/23/25. Patient 5 Review of Patient 5’s clinical record showed a Start of Care date of 04/15/24 with orders for Physical Therapy to evaluate the patient for services. Review of the Physical Therapy evaluation note in the EMR dated 05/01/25 was blank. Patient 6 Review of Patient 6’s clinical record showed a Start of Care date of 11/22/24 with a current episode dated 05/21/25 - 07/19/25. Review of episode 05/21/25 - 07/19/25 showed Physical Therapy visits were ordered to be made one time per week for four weeks. Physical Therapy visits scheduled and dated 06/13/25, 06/20/25 and 06/23/25 were blank in the EMR. Patient 7 Review of Patient 7’s clinical record showed a Start of Care date of 04/10/25 with a current episode dated 06/09/25 - 08/07/25. Review of episode 06/09/25 - 08/07/25 showed Physical Therapy visits were ordered to be made two time per week for three weeks, then one time per week for one week. Review of clinical visit notes for episode 06/09/25 - 08/07/25 showed Physical Therapy visits had been made on 06/10/25, 06/12/25, 06/17/25, and 06/19/25 which was only two times for two weeks. When questioned if Physical Therapy had made all of the ordered visits or had discharged the patient early, the agency administrator indicated that the visits had been made. During an interview on 08/14/25 at 3:15 PM, Staff A, Administrator, confirmed the above findings of the patient’s clinical record containing all the required information from OASIS Assessments and documented therapy notes. She stated, “therapy uses a different system and we have to scan it into our record and we are behind on doing that.””