Cypress Home Health

“EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: Based on interview and record review, the agency failed to ensure the Emergency Preparedness Plan addressed patient populations and types of services the HHA has the ability to provide in an emergency. Review of the Agency’s Emergency Preparedness Plan revealed no evidence the patient population or types of services the Home Health Agency has the ability to provide in an emergency was addressed. An interview was conducted with S1ADM on 05/15/2024 at 11:55 a.m. He confirmed the agency did not address the patient population and the services the agency could provide during a disaster. He stated there was no documentation to show any specific needs patients’ required during an emergency or disaster. He stated he was unaware of the needs patients’ required in the event of a disaster.”

“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 record review and interview, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the CMS system within 30 days of completion. Review of the agency’s policy titled, “OASIS Data Transmission” with a revision date of April 2018 revealed the following, in part: Purpose: To outline the OASIS data transmission requirements. Policy: The organization will adhere to all OASIS data transmission requirements as outlined in the Medicare Conditions of Participation, Reporting of OASIS Information. Procedure: 1. The organization will encode and transmit completed OASIS data for each applicable patient within thirty days of the M0090 date, date assessment completed. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 02/09/2024 revealed 77 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 02/12/2024 revealed 44 records were processed with 2 records receiving a message the records were submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 03/15/2024 revealed 108 records were processed with 2 records receiving a message the records were submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 03/26/2024 revealed 72 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 04/05/2024 revealed 69 records were processed with 3 records receiving a message the records were submitted late due to a submission date of more than 30 days after date on the record. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 04/23/2024 revealed 140 records were processed with 5 records receiving a message the records were submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted with S9BIL on 05/15/2024 at 2:55 p.m. She confirmed she was responsible for submitting the agency’s OASIS Assessments. She stated she submitted OASIS Assessments every couple of weeks regardless of completion dates. She confirmed the above listed OASIS Agency Final Validation Reports had messages the OASIS was submitted late. She stated the requirement was to submit the OASIS within 30 days of completion.”

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the OASIS data accurately reflected the patient’s status at the time of assessment. The agency inaccurately documented a patient had been treated for Urinary Tract Infection for 1 (#15) of 17 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17) sampled patient records reviewed. Findings: Review of the agency’s policy titled, “OASIS Data Transmission” with a revision date of 04/2018 revealed the following, in part: Purpose: To outline the OASIS data transmission requirements. Policy: The organization will adhere to all OASIS data transmission requirements as outlined in the Medicare Conditions of Participation, Reporting of OASIS Information. Procedure: 2. The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. Review of the Clinical Record for Patient #15 revealed she began receiving services from the Home Health Agency on 09/09/2023, and was discharged from the agency on 10/27/2023. Patient #15 had a diagnosis of Zoster without complications. Further review revealed Patient #15 was ordered to receive Skilled Nursing visits once weekly for one week, twice weekly for one week and once weekly for six weeks for Certification Period of 09/09/2023 to 11/07/2023. Review of the Skilled Nurse visit note dated 09/27/2023 for Patient #15 revealed the following, in part: Narrative: Bactrim was added to the patient’s medication regimen for Shingles rash. Review of the Medication Profile for Certification Period of 09/09/2023 to 11/07/2023 for Patient #15 revealed the following, in part: Start date 09/19/2023: Bactrim DS 800 mg-160 mg tablet take one tablet daily. Reason: Shingles. Review of the Discharge OASIS dated 10/27/2023 for Patient #15 and completed by S3RN revealed the following, in part: Has the patient been treated for a Urinary Tracy Infection in the past 14 days? 1-Yes An interview was conducted with S2DON on 05/15/2024 at 11:37 a.m. She reviewed Patient #15’s clinical record and verified she was prescribed Bactrim for drainage from a Shingles rash. She verified there was no documentation of Patient #15 having a Urinary Tract Infection during the Certification Period of 09/09/2023 to 11/07/2023. She confirmed Patient #15’s Discharge OASIS dated 10/27/2023 was not accurately coded and should have been.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observations during home visits, interviews, and record review, the agency failed to ensure each patients’ comprehensive assessment included a review of all medications the patients were currently using. The agency failed to ensure skilled nursing staff reconciled patients’ medications for 5 (#2, #4, #5, #6 and #7) of 7 (#1, #2, #3, #4, #5, #6 and #7) patients reviewed with home visits. Review of the agency’s policy titled, “Medication Reconciliation” with a revision date of 10/2013 revealed the following, in part: Policy: The agency will reconcile patient’s medications at time of admission and on an ongoing basis, no less than every 60-62 days. Procedure: 2. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication… Patient #2 Review of the Clinical Record for Patient #2 revealed she began receiving services from the Home Health Agency on 04/13/2024 and had a current Certification Period of 04/13/2024 to 06/11/2024. Patient #2 had diagnoses, which included Adhesive Capsulitis of Left Shoulder. Further review revealed Patient #2 was ordered to receive Skilled Nursing Visits once weekly for ten weeks for Certification Period of 04/13/2024 to 06/11/2024. A home visit was conducted on 05/13/2024 at 2:30 p.m. with Patient #2, her sitter, and S6ST present in the home. Patient #2’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #2’s Current Medication Profile provided by the Home Health Agency: Brimonidine Tartrate 2% present in the home but not on the medication profile. An interview was conducted with Patient #2 and her sitter during the home visit. Patient #2’s sitter confirmed the medication list in the home revealed Patient #2 had been using Brimonidine Tartrate 2% one drop both eyes twice daily since 10/24/2023. Patient #2 confirmed she was using Brimonidine Tartrate 2% one drop in both eyes twice daily. An interview was conducted with S6ST during the home visit. She stated the nurse was responsible to reconcile Patient #2’s medications during each visit. Patient #4 Review of the Clinical Record for Patient #4 revealed she began receiving services from the Home Health Agency on 05/02/2024 and had a current Certification Period of 05/02/2024 to 06/30/2024. Patient #4 had diagnoses, which included Pneumonia and Sepsis Due to Pseudomonas. Further review revealed Patient #4 was ordered to receive Skilled Nursing Visits once weekly for one week, twice weekly for one week, and once weekly for seven weeks for Certification Period of 05/02/2024 to 06/30/2024. A home visit was conducted on 05/14/2024 at 10:15 a.m. with Patient #4 and S7PT present in the home. Patient #2’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #4’s Current Medication Profile provided by the Home Health Agency: (Fill date: 12/05/2023) Azithromycin 250 mg PO three times weekly was present in the home and not on the medication profile. An interview was conducted with Patient #4 during the home visit. Patient #4 stated she had been taking Azithromycin for a while. Patient #5 Review of the Clinical Record for Patient #5 revealed she began receiving services from the Home Health Agency on 06/09/2023 and had a current Certification Period of 04/04/2024 to 06/02/2024. Patient #5 had diagnoses, which included Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side and Thrombocytopenia. Further review revealed Patient #5 was ordered to receive Skilled Nursing Visits once weekly for one week and once every two weeks for six weeks effective week of 04/14/2024 for Certification Period of 04/04/2024 to 06/02/2024. A home visit was conducted on 05/14/2024 at 12:40 p.m. with Patient #5, S8HH, and Patient #5’s husband present in the home. Patient #5’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #5’s Current Medication Profile provided by the Home Health Agency: Amicar 250mg /ml (25%) oral solution take 4ml by mouth every 6 hours was on the medication profile and not present in the home. Lactulose 10 gram/15 ml (15 ml) oral solution take 15 mL as directed on MWF was on the medication profile, and patient was taking 15 mL by mouth twice daily. An interview was conducted with Patient #5’s husband during the home visit. He stated he managed Patient #5’s medications. He stated Patient #5 had not taken Amicar in months and had taken Lactulose 15 mL twice daily for years. Patient #6 Review of the Clinical Record for Patient #6 revealed she began receiving services from the Home Health Agency on 03/01/2024 and had a current Certification Period of 04/30/2024 to 06/28/2024. Patient #6 had diagnoses, which included Unspecified Dementia and Major Depressive Disorder. Further review revealed Patient #6 was ordered to receive Skilled Nursing Visits once weekly for nine weeks effective week of 04/28/2024 for Certification Period of 04/30/2024 to 06/28/2024. A home visit was conducted on 05/14/2024 at 8:30 a.m. with Patient #6, her sitter, and S4RN present in the home. Patient #6’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #6’s Current Medication Profile provided by the Home Health Agency: Sertraline 100 mg tablet take one tablet daily was on the medication profile with a start date of 03/27/2024 and the patient was no longer taking. Escitalopram 10 mg take one tablet daily by mouth was present in the home and not on the medication profile. Medication bottle present in the home with a filled date of 03/21/2024 and the patient was currently taking. An interview was conducted with Patient #6’s sitter during the home visit. She stated she assisted Patient #6 with managing her medications and filled her pill box weekly. She stated on 03/21/2024, Patient #6’s physician added Escitalopram 10 mg daily and weaned the Sertraline 100 mg by decreasing to half a tablet every other day starting on 03/21/2024 and was stopped on 03/28/2024. An interview was conducted with S4RN on 05/14/2024 at 9:00 a.m. during the home visit. She stated each patients’ medications should be reconciled every visit by asking the patient if they had any medication changes and compare the medication profile to the medication bottles. She stated she saw Patient #6 often. She reviewed Patient #6’s clinical record and stated on 03/27/2024 she was aware of and documented the above medication changes in her visit note. She stated she forgot to update Patient #6’s medication profile. She further stated she saw Patient #6 for a visit last week on 05/08/2024. She confirmed the medications the patient was taking and the home health medication list did not match and should have. Patient #7 Review of the Clinical Record for Patient #7 revealed she began receiving services from the Home Health Agency on 05/02/2024 and had a current Certification Period of 05/02/2024 to 06/30/2024. Patient #7 had diagnoses, which included Diastolic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Acute on Chronic Respiratory Failure with Hypoxia and Acute on Chronic Respiratory Failure with Hypercapnia. Further review revealed Patient #7 was ordered to receive Skilled Nursing Visits once weekly for one week, twice weekly for one week and once weekly for seven weeks for Certification Period of 05/02/2024 to 06/30/2024. A home visit was conducted on 05/15/2024 at 10:15 a.m. with Patient #7 and S5OT present in the home. Patient #7’s medications were reviewed during the home visit. The following medication discrepancy was identified when compared to Patient #7’s Current Medication Profile provided by the Home Health Agency: Oxygen at 2 liters as needed was on the medication profile as discontinued and the patient was currently using. An interview was conducted with Patient #7 during the home visit. She was observed wearing oxygen at 2 Liters per minute via nasal cannula. She stated she used oxygen as needed and had been using it for the last few days. An interview was conducted with S2DON on 05/15/2024 at 11:25 a.m. She was notified of the medication discrepancies found during the home visits for Patient #2, #4, #5, #6, and #7. She verified each patients’ Medication Profile should have reflected what the patient was currently taking. She stated Patient #7’s oxygen, even if used as needed should stay on the patient’s active medication list and not be discontinued.”

“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, who was familiar with the patient and the patient’s plan of care, made an onsite visit to the patient’s home no less than every 14 days for aide supervisory visits for 1 (#10) of 3 (#5, #9, and #10) sampled patients’ with Home Health Aide (HHA) Services out of a total sample of 17 patients. Findings: Review of the agency’s policy titled, “Home Health Aide Supervision” with a revision date of 10/2013 revealed the following, in part: Policy: All home health aide supervisory visits will be made according to Agency policy and State standards. Purpose: To assure Home Health Aide supervision is compliant with Agency policy and State standards, ensure appropriateness of home health aide services and to maintain quality of care. Procedure: 2. If the patient is receiving a skilled service (nursing, physical therapy, occupational therapy, or language pathology) the supervisory visits shall be made to the patients residence at least once every two (2) weeks by the appropriate therapist to assess relationships and determine whether goals are being met. Review of the Clinical Record for Patient #10 revealed she began receiving services from the Home Health Agency on 04/12/2024 and had a current Certification Period of 04/12/2024 to 06/10/2024. Patient #10 had diagnoses, which included Peripheral Vascular Disease, Other Chronic Pain, Dependence on Supplemental Oxygen, and Morbid Severe Obesity due to Excess Calories. Further review revealed Patient #10 was ordered to receive Home Health Aide visits twice weekly for three weeks effective week of 04/14/2024 for Certification Period of 04/12/2024 to 06/10/2024. Review of HHA visit notes during the current Certification Period of 04/12/2024 to 06/10/2024 revealed documentation of the following HHA visits conducted: 04/16/2024, 04/19/2024, 04/23/2024, 04/26/2024, 04/29/2024 and 05/03/2024. Review of the Skilled Nurse visit documentation revealed no documentation a HHA supervisory visit was conducted by a registered nurse during the current Certification Period. An interview was conducted with S2DON on 05/15/2024 at 11:33 a.m. She reviewed the electronic record for Patient #10 and confirmed the Home Health Aide was ordered and visits were made twice weekly for three weeks for the current Certification Period. She verified aide supervisory visits were not conducted by a registered nurse every 14 days as required.”