Audubon Home Health of Hammond

“Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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 the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: Based on record review and interviews, the agency failed to develop and maintain an Emergency Preparedness (EP) Plan at least every 2 years which included a facility-based and community-based risk assessment. This deficient practice had the potential to affect all 156 patients, according to the agency’s current census. Findings: Review of the agency’s policy titled “Natural Disasters/Emergencies”, with a revision date of April 2018, revealed in part: Procedure: Additional or alternate guidelines should be included by the organization based on its hazard vulnerability analysis and subsequent plan. Review of the agency’s January 2024 EP Plan revealed there was no facility-based and community- based risk assessment included or available for review. An interview was conducted with S2DON on 03/14/2025 at 2:00 p.m. S2DON stated she did not know a risk assessment should be included with the agency’s EP Plan. S2DON confirmed the agency had not completed a facility-based and community-based risk assessment for the 2024 EP Plan and should have. An interview was conducted with S4DOO on 03/14/2025 at 2:50 p.m. S4DOO was made aware of the above missing risk assessment documentation. S4DOO stated the agency should be in compliance with all state laws and regulations and was not.”

“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 Centers for Medicare and Medicaid Services (CMS) system within 30 days of completion. Findings: Review of the agency’s policy titled, “OASIS Data Transmission”, with a revision date of April 2018, revealed 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 01/28/2025 revealed 22 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 02/03/2025 revealed 38 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 02/06/2025 revealed 2 records were processed with 2 records 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 02/24/2025 revealed 56 records were processed with 3 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted with S2DON on 03/14/2025 at 2:00 p.m. S2DON confirmed the above records were submitted late. S2DON stated OASIS Assessments should have been submitted within 30 days of completion.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on record reviews and interview, the agency failed to have the Plan of Care (PoC) reviewed and revised by the physician every 60 days, beginning with the SOC (Start of Care) date for 2 (#7 and #16) of 17 (#1-#17) sampled patients reviewed. This deficient practice had the potential to affect all 156 patients, according to the agency’s current census. Findings: Review of the agency’s policy titled “Reassessments/Recertification” with a revision date of April 2018, revealed in part: Policy The comprehensive assessment must be updated and revised every 60 days beginning with the start of care. Procedure 12. The updated plan of care will be prepared and sent to the physician for review and signature in a timely manner. Patient #7 Review of Patient #7’s Clinical Record revealed Patient #7’s SOC date was 10/23/2024. Review of the PoC for certification period 10/23/2024 through 12/21/2024 revealed the physician did not sign the PoC until 03/14/2025. Patient #16 Review of Patient #16’s Clinical Record revealed Patient #16’s SOC date was 03/12/2024. Review of the PoC for certification period 03/12/2024 through 05/10/2024 revealed the physician did not sign the PoC until 07/08/2024. An interview was conducted with S2DON on 03/14/2025 at 2:00 p.m. The above PoC for Patient #7 and Patient #16 were reviewed. S2DON confirmed all PoC orders should be reviewed and signed by the physician within 60 days, and Patient #7 and Patient #16’s were not.”

“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 reviews and interviews, the agency failed to ensure a Home Health Aide Supervisory Visit was conducted every fourteen days for 1 (#5) patient with Home Health Aide Services, out of a total sample of 17 patients reviewed. Findings: Review of the agency’s policy titled “Home Health Aide Supervisory Visits”, with a revision date of April 2018, revealed in part: Policy: The registered nurse or other appropriate skilled professional familiar with the patient, the patient’s plan of care, and written patient care instructions must conduct supervisory visits to the patient’s residence at regular intervals. Procedure: 1. The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days. Review of Patient #5’s Clinical Record revealed he began receiving services from the agency on 01/03/2025, with a prior certification period of 01/03/2025 through 03/03/2025, and a current certification period of 03/04/2025 through 05/02/2025. Review of Patient #5’s Physician Ordered discipline frequency revealed he received Home Health Aide visits two times a week for four weeks beginning 02/03/2025, then one time a week for nine weeks beginning 03/04/2025. Review of Patient #5’s Home Health Aide visit calendar revealed, in part, he had visits completed on 02/03/2025, 02/07/2025, 02/10/2025, 02/13/2025, 02/17/2025, 02/20/2025, 02/24/2025, 02/27/2025, 03/04/2025 and 03/13/2025. Review of Patient #5’s Nursing visit calendar revealed, in part, he had Nursing visits completed on 02/03/2025, 02/10/2025, 02/20/2025 and 03/05/2025 by S14LPN, and on 02/27/2025 by S6RN. Review of Patient #5’s Nursing Visit notes revealed a Home Health Aide Supervisory Visit was not conducted the week of 02/21/2025. Review of Patient #5’s Occupational Therapy (OT) visit calendar revealed, in part, he had OT visits completed on 02/07/2025, 02/27/2025, and 03/13/2025. Review of Patient #5’s Occupational Therapy Visit Notes revealed a Home Health Aide Supervisory Visit was conducted on 02/07/2025 by S11OT. Further review revealed a Home Health Aide Supervisory Visit was not conducted the week of 02/21/2025. A telephone interview was conducted with S14LPN on 03/14/2025 at 1:55 p.m. S14LPN stated she was assigned to see Patient #5 alternating with S6RN. S14LPN stated Patient #5 was seen by her on 02/20/2025. S14LPN stated S6RN and S11OT were not scheduled to see Patient #5 the week of 02/20/2025. S14LPN confirmed a Home Health Aide Supervisory Visit was not conducted every 14 days and should have been. A telephone interview was conducted with S11OT on 03/14/2025 at 2:03 p.m. S11OT reviewed Patient #5’s Clinical Record and confirmed a Home Health Aide Supervisory Visit was not conducted every 14 days and should have been. An interview was conducted with S2DON on 03/14/2025 at 2:08 p.m. S2DON stated a Home Health Aide Supervisory Visit should be conducted by either a Registered Nurse or OT every 14 days. S2DON reviewed Patient #5’s Clinical Record and confirmed a Home Health Aide Supervisory Visit was not conducted every 14 days and should have been.”