Capuano Home Health Care Inc.

“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 document review and staff interview, the agency failed to ensure Outcome and Assessment Information Set (OASIS) assessments were transmitted to Centers for Medicare and Medicaid Services (CMS) within 30 days of completing the assessment of the beneficiary, as required. Findings include: Review of the agency’s Home Health Agency Error Summary Report, dated 4/12/24 through 9/10/24, indicated that 88 of 933 OASIS Assessments processed, were submitted more than 30 days after completion. During an interview on 9/12/24 at 1:45 P.M., the Administrator said that the data on the Error Summary Report was correct, and those 88 OASIS Assessments were submitted late. She said there was no pattern to why they had been submitted late but were not submitted timely as required.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on clinical record review, policy review, and interview, the Agency failed to ensure home health services that are written in an individualized plan of care (POC) that identifies patient-specific measurable outcomes and goals, were provided for 3 Patients (#1, #7 and #8), out of a total sample of 8 patients. Findings include: Review of the agency policy, titled, Missed Visits, revised April 2021, included the following: *If a visit is missed for any reason, the clinician should attempt to reschedule if the same day/week so that the physician ordered frequency is maintained and would not be considered a missed visit. *If a visit is missed and not rescheduled the clinician will: Notify the clinical supervisor of the missed visit and reason for the missed visit. Document in the patient’s clinical record the following information: Patient name, date and type of visit that was missed, reason for the missed visit, any other follow-up needed, other person(s) that were notified of the missed visit, signature of staff member reporting the information. 1. Patient #1 was admitted to the Agency in June 2024 with a diagnosis of Multiple Sclerosis (a disease in which the immune system eats away at the protective covering of the nerves). Review of the Physician orders for the Home Health Certification period, 6/25/24 through 8/23/24, indicated the following: *Effective 7/7/24: Occupational Therapy visit (OTV) 1 to 2 times a week for 7 weeks. Review of the Physician orders for the Home Health Certification period, 8/24/24 through 10/22/24 indicated the following: Effective 8/27/24: OTV 1 to 2 times per week for 9 weeks. Review of the clinical record for Patient #1 failed to indicate that OTVs were provided for the week of 8/18/24 and the week of 9/1/24. There was no documentation as to why the visits were not provided. During an interview on 9/11/24 at 1:40 P.M., the Business Director said that missed visits should be documented in the clinical record During an interview on 9/11/24 at 2:07 P.M., the Business Director said that he had reviewed the clinical record and was not able to find documentation for the missed OTVs for the weeks of 8/18/24 and 9/1/24, and services were not provided as ordered. 2. Patient #7 was admitted to the Agency in February 2024 with a diagnosis of Diabetes Mellitus (a disease that occurs when the body cannot produce or use insulin properly, causing high blood sugars). Review of the Physician ordered Home Health Certification POC, dated 2/2/24 through 4/21/24, included the following orders: *Effective 2/22/24: 1 Skilled Nurse visit (SNV) 1 time a day for 10 weeks. Review of the clinical record indicated that a SNV was not provided as ordered on 2/24/24 and 4/7/24. During an interview on 9/12/24 at 2:30 P.M., the Director of Business said the POC was not followed, as ordered. He also said nursing did not document why the 2 visits were missed. 3. Patient #8 was admitted to the Agency in April 2024 with a diagnosis of bilateral hip osteoarthritis (a degenerative joint disease which involves the tissues in the joint). Review of the Physician ordered Home Health Certification POC, dated 7/31/24 through 9/28/24, included the following orders: *Effective 8/20/24: 1 Home Health Aide visit (HHAV) 3x a week for 6 weeks. Review of the clinical record indicated Patient #8 had been hospitalized 8/21/24 through 9/3/24. Review of the clinical record indicated no HHA visits between 9/4/24 and 9/7/24. Additionally, the record indicated only 1 HHAV was provided (9/9/24) between 9/8/24 and 9/12/24. During an interview on 9/12/24, the Director of Business said the HHAVs were not provided as ordered for Patient #8, and there was no documentation indicating why the visits were not provided.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interviews and policy review, the Agency failed to ensure that 1 of 3 clinicians (Registered Nurse #1) observed during home visits, adhered to infection control practices to limit the risk of spread of infection. Findings include: Review of the agency policy, titled, Safety Medication Assistance and Administration Policy and Procedure, effective 3/8/2020, included the following: -Infection control procedures will be followed throughout the medication administration process Review of the agency policy, titled, Narcotic Count Sheet, approved 9/1/2021, included the following: -All controlled medications must be counted safely and on a clean surface as to not contaminate the medication On 9/12/24 at 9:30 A.M., the surveyor observed Nurse #1 administer and prefill medications for Patient #5. Nurse #1 performed hand hygiene and donned gloves. She contaminated her gloves by touching the outside of the lockbox. She opened a container, poured a pill into the cap of the container and then placed the pill into a medication organizer. With the same gloves she touched her electronic device to document the medication, further contaminating her gloves. During the process a capsule fell from the container onto the top of the lockbox and Nurse #1 picked it up and placed the contaminated capsule into the medication organizer. With the same gloves on Nurse #1 again opened the lockbox, removed a medication container and poured a pill into her gloved hand and then into the medication organizer. Three times she removed medications from the lockbox the lid closed, and she had to reopen the lockbox, further contaminating her gloves. When the administration was completed Nurse #1 counted a controlled medication by pouring the pills from the container into her contaminated gloved hand and then putting them back into the container. During an interview on 9/12/24 at 9:45 A.M., Nurse #1 said that she should not have administered a medication that had fallen, should not have put medications into a contaminated glove hand before placing them in a medication organizer and should have used a clean surface to count controlled medication. During an interview on 9/12/24 at 10:20 A.M., the Business Director said that medication that has fallen should not be administered, medications should not be poured into a contaminated gloved hand and controlled medications should be counted on a clean surface.”

“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 clinical record review, policy review and staff interview, the Agency failed to ensure the Registered Nurse conducted an initial assessment within 48 hours of the referral date for 2 patients (#8 and #2), from a total sample of 8 patients. Findings include: Review of the clinical record indicated that Patient #2 had a referral date of June 6, 2024 and a diagnosis of Lymphoedema. The referral indicated that the patient was homebound requiring skilled nursing services for indwelling catheter and wound care. The documented referral date for Patient #2 was June 6, 2024. The start of care date was documented as June 14, 2024, 8 days past the referral date, with no documented reason for the delay. During an interview on 9/12/24 at 9:05 A.M., the Business Director said he spoke with the nurse who said that Patient #2 was not discharged from the prior agency until 6/10/24. He further said that the expectation is that the nurse should have documented this information in the clinical record. Review of the Agency’s policy entitled, Intake Process, dated April 2021, indicated the following: *The organization accepts only those patients whose needs can be met by the services it provides. *Patient referrals for home care services may be accepted by clinicians, including the director, supervisor, and intake coordinator. *The Clinical Supervisor/Intake Coordinator will assign personnel and schedule an initial assessment visit. The initial assessment visit will be performed either within 48 hours of the referral, or within 48 hours of a patient’s return home, or on the start of care dated ordered by the physician (or other authorized licensed independent practitioner). *If the patient cannot be assessed within the timeframe specified, a call log and/or physician ordered (IPO) will be completed. 1. Review of the clinical record of Patient #8 indicated a referral date of 3/21/24. Patient #8 was admitted to the Agency in April 2024 with a diagnosis of bilateral hip osteoarthritis (a degenerative joint disease that can affect the many tissues of the joint). Further review of the clinical record indicated the initial assessment was not completed until 4/2/24. During an interview on 9/12/24 at 1:55 P.M., after reviewing Patient #8’s clinical record, the Business Director said the initial assessment was not done within the required timeframe and there was no document to indicate why it was completed late.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on clinical record review, interview and policy review, the agency failed to ensure that 1.) the clinician prepared clinical notes for 1 Patient (#4), and 2.) failed to ensure clinical notes were completed timely for 3 Patients (#6, #7 and #8), out of a total sample of 8 patients. Findings include: 2. For Patient #2, the Home Health Agency failed to document why there was a delay in starting home health services within 48 hours from the referral date. Patient #2 was admitted to the Agency in June 2024 with a diagnosis of lymphoedema. Review of the clinical record indicated that Patient #2 had a documented referral date of June 6, 2024, but his/her start of care was documented as June 14, 2024, 8 days after the referral was made. During an interview on 9/12/24 at 9:05 A.M., the Business Director said he contacted the nurse involved who said Patient #2 was not discharged from the previous agency until 6/10/24, but she did not document this in the clinical record. The Business Director said the expectation is the nurse should have documented this information in the clinical record. 3. For Patient #6, the Agency failed to ensure that the Physical Therapist completed his documentation with 48 hours per policy for Patient #6. Patient #6 was admitted to the Agency In January 2024 with a diagnosis of Multiple Sclerosis. Review of the clinical record indicated that during the certification period of 1/22/24 - 3/21/24 the patient was to receive physical therapy service 1-2 times a week for 9 weeks. Further review of the clinical record indicated that for 6 of 9 visits the documentation for the visits were signed and dated as completed after 48 hours, including the following: *The Physical therapy home visit was conducted on 1/22/24, but documentation for the visit was not signed and dated until 1/26/24. *The Physical therapy home visit was conducted on 2/1/24, but documentation for the visit was not signed and dated until 2/8/24. *The Physical therapy home visit was conducted on 2/6/24, but documentation for the visit was not signed and dated until 2/13/24. *The Physical therapy home visit was conducted on 2/9/24, but documentation for the visit was not signed and dated until 2/15/24. *The Physical therapy home visit was conducted on 3/8/24, but documentation for the visit was not signed and dated until 3/19/24. *The Physical therapy home visit was conducted on 3/12/24, but documentation for the visit was not signed and dated until 3/19/24. During an interview on 9/12/24 at 1:25 P.M., the Business Director said the documentation for the visit should be completed within 48 hours, per the Agency’s policy. Review of the agency policy, titled, Missed Visits, revised April 2021, included the following: -If a visit is missed and not rescheduled the clinician will: Document in the patient’s clinical record the following information: Patient name, date and type of visit that was missed, reason for the missed visit, any other follow-up needed, other person(s) that were notified of the missed visit, signature of staff member reporting the information. Review of the Occupational Therapy (OT) orders for certification period 6/25/24 through 8/23/24 indicated the following OT order: Start on 7/7/24 1-2 times for 7 weeks. Review of the OT orders for certification period 8/24/24 through 10/22/24 indicated the following OT order: Start on 8/27/24 1-2 times per week for 9 weeks. Review of the clinical record for Patient #1 failed to indicate that OT was provided for the week of 8/18/24 and the week of 9/1/24. There was no documentation as to why the visits were missed. During an interview on 9/11/24 at 1:40 P.M., the Business Director said that missed visits should be documented in the clinical record. During an interview on 9/11/24 at 2:07 P.M., the Business Director said that he had reviewed the clinical record and was not able to find documentation for the missed OT visits for the weeks of 8/18/24 and 9/1/24. Review of the Agency’s policy entitled, Clinical Signatures on Visit Notes, dated 3/19/21, indicated the following: *The Agency must maintain updated, accurate, and complete visit notes. *Applies to all field staff who complete patient visits. *All visits must be signed by the clinician who completed the care within 48 hours of the date of the visit. *In the event the clinician is unable to meet the 48 hour requirement, the clinician must communicate with the supervisor to discuss and determine a deadline for completion. 1. For Patient #4, the Agency staff failed to document the reason the initial assessment was not completed within 48 hours of the referral date. Patient #4 was admitted to the Agency in July 2024 with a diagnosis of cerebral infarction (damage to the tissues in the brain due to a loss of oxygen to the area). Review of the clinical record indicated a referral date of 7/23/24, and the initial assessment (start of care) visit was documented as completed on 7/31/24. Review of the late entry note, dated 9/11/24, indicated the Physical Therapist spoke with Patient #4’s spouse on 7/25/24, who requested a delay of the initial visit to 7/31/24, when the Physical Therapist would be available. During an interview on 9/12/24 at 9:30 A.M., the Director of Business said he reached out to the Physical Therapist who said he failed to document his phone conversation with Patient #4’s spouse to delay the initial assessment. 2a.) For Patient #6, the Agency failed to ensure that the Physical Therapist completed his documentation with 48 hours per policy for Patient #6. Patient #6 was admitted to the Agency In January 2024 with a diagnosis of Multiple Sclerosis. Review of the clinical record indicated that during the certification period of 1/22/24 - 3/21/24 the patient was to receive physical therapy (PT) service 1-2 times a week for 9 weeks. Further review of the clinical record indicated that for 6 of 9 visits the documentation for the visits were signed and dated as completed after 48 hours, including the following: *The PT home visit was conducted on 1/22/24, but documentation for the visit was not signed and dated until 1/26/24. *The PT home visit was conducted on 2/1/24, but documentation for the visit was not signed and dated until 2/8/24. *The PT home visit was conducted on 2/6/24, but documentation for the visit was not signed and dated until 2/13/24. *The PT home visit was conducted on 2/9/24, but documentation for the visit was not signed and dated until 2/15/24. *The PT home visit was conducted on 3/8/24, but documentation for the visit was not signed and dated until 3/19/24. *The PT home visit was conducted on 3/12/24, but documentation for the visit was not signed and dated until 3/19/24. During an interview on 9/12/24 at 1:25 P.M., the Business Director said the documentation for the visit should be completed within 48 hours, per the Agency’s policy. 2b.) For Patient #7, the Agency failed to ensure that nursing staff signed and dated their visit notes within 48 hours of the visit. Patient #7 was admitted to the Agency in February 2024 with a diagnosis of Diabetes Mellitus (a disease that occurs when the body cannot produce or use insulin properly, causing high blood sugars). Review of the Physician ordered Home Health Certification POC, dated 2/2/24 through 4/21/24, included the following orders: *Effective 2/22/24: 1 Skilled Nurse visit (SNV) a day for 10 weeks. Review of the clinical record indicated a SNV was made on 2/22/24, however it was not signed and dated until 2/25/24. Review of the clinical record indicated a SNV was made on 2/23/24, however it was not signed and dated until 2/27/24. Review of the clinical record indicated SNVs were made on 2/26/24, 2/28/24 2/9/24 and 3/2/24 however then of the notes were not signed and dated until 3/5/24. Review of the clinical record indicated SNVs were made on 3/7//24, 3/8/24, and 3/9/24 however then of the notes were signed and dated until 3/12/24. Review of the clinical record indicated a SNV was made on 3/11/24, however it was not signed and dated until 3/16/24. Review of the clinical record indicated a SNV was made on 3/12/24, however it was not signed and dated until 3/15/24. Review of the clinical record indicated SNVs were made on 3/13/24, however it was not signed and dated until 3/16/24. Review of the clinical record indicated SNVs were made on 3/25/24 and 3/27/24, however the notes were not signed and dated until 4/1/24. Review of the clinical record indicated a SNV was made on 4/28/24, however it was not signed and dated until 4/2/24. Review of the clinical record indicated a SNV was made on 4/1/24, however it was not signed and dated until 4/5/24. Review of the clinical record indicated a SNV was made on 4/2/24, however it was not signed and dated until 4/6/24. Review of the clinical record indicated a SNV was made on 4/17/24, however it was not signed and dated until 4/24/24. Review of the Physician’s ordered Home Health Certification POC, dated 4/22/24 through 6/20/24, included the following orders: *Effective 4/22/24: 1 Skilled Nurse visit (SNV) a day for 9 weeks. Review of the clinical record indicated SNVs were made on 4/24/24 and 4/26/24, however the notes were not signed and dated until 4/29/24. Review of the clinical record indicated a SNV was made on 5/2/24, however it was not signed and dated until 5/5/24. Review of the clinical record indicated a SNV was made on 5/6/24, however it was not signed and dated until 5/9/24. Review of the clinical record indicated SNVs were made on 5/9/24 and 5/10/24, however the notes were not signed and dated until 5/14/24. Review of the clinical record nursing completed the discharge summary, however it was not signed and dated until 6/2/24. 2c.) For Patient #8, the Agency failed to ensure that staff, including the Physical Therapist, the Occupational Therapist and Nursing, signed their visit notes within 48 hours of their visits. Patient #8 was admitted to the Agency in April 2024 with a diagnosis of bilateral hip osteoarthritis (a degenerative joint disease which involves the tissues in the joint). Review of the Physician ordered Home Health Certification POC, dated 4/2/24 through 5/31/24, included the following orders: *Effective 4/2/24: Physician Therapy visit (PTV) once a day for one day. *Effective 4/8/24: 1 to 2 PTVs a week for 8 weeks. Review of the clinical record indicated a PTV was made on 4/2/24, however it was not signed and dated until 4/8/24. Review of the clinical record indicated a PTV was made on 5/3/24, however it was not signed and dated until 5/8/24. Review of the clinical record indicated a PTV was made on 5/31/24, however it was not signed and dated until 6/5/24. Review of the Physician ordered Home Health Certification POC, dated 6/1/24 through 7/30/24, included the following orders: *Effective 6/5/24: 1 PTV a week for one week, then 1 to 2 PTVs week for 8 weeks. *Effective 6/11/24: 1 Occupational Therapy visit (OTV) a week for 1 week. *Effective 6/16/24: 1 to 2 OTVs a week for 7 weeks. Review of the clinical record indicated an OTV was made on 6/13/24, however it was not signed and dated until 6/16/24. Review of the clinical record indicated a PTV was made on 6/28/24, however it was not signed and dated until 7/5/24. Review of the clinical record indicated a PTV was made on 7/26/24, however it was not signed and dated until 8/1/24. Review of the clinical record indicated an OTV was made on 7/30/24, however it was not signed and dated until 8/4/24. Review of the Physician ordered Home Health Certification POC, dated 7/31/24 through 9/28/24, included the following orders: *Effective 8/4/24: 1 to 2 PTVs a week for 8 weeks. *Effective 9/5/24: 1 OTV a week for 1 week, and 1 Skilled Nurse visit (SNV) a day for 1 day. Review of the clinical record indicated a PTV was made on 9/4/24, however it was not signed and dated until 9/8/24. Review of the clinical record indicated an OTV was made on 9/5/24, however it was not signed and dated until 9/8/24. Review of the clinical record indicated a SNV was made on 9/5/24, however it was not signed and dated until 9/11/24. During an interview on 9/12/24 at 9:35 A.M., the Director of Business said staff are required to sign and date their documented visit within 48 hours of the visit, and if they are not able to there should be documentation to indicate why a note was not completed timely. During a second interview on 9/12/24 at 2:30 P.M., the Director of Business said he had reviewed the clinical records for Patients #7 and #8. He said that staff had completed the above noted documentation late and not within 48 hours of their visit as the agency requires.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on clinical record review and interview, the Agency failed to ensure the staff communicated to the physician when there was a change in the plan of care (POC) for 2 patients (#8 and #7), out of a total sample of 8 patients. Findings include: Patient #8 was admitted to the Agency in April 2024 with a diagnosis of bilateral hip osteoarthritis (a degenerative joint disease which involves the tissues in the joint). Review of the Physician ordered Home Health Certification POC, dated 4/2/24 through 5/31/24, included the following orders: *Effective 4/2/24: Physician Therapy visit (PTV) once a day for one day. *Effective 4/8/24: 1 to 2 PTVs a week for 8 weeks. Review of the clinical record included documented notes that PTVs were not provided on 5/7/24, 5/21/24, and 5/23/24, however the notes did not indicate the physician was notified of the missed visits. Review of the Physician ordered Home Health Certification POC, dated 6/1/24 through 7/30/24, included the following orders: *Effective 6/5/24: 1 PTV a week for one week, then 1 to 2 PTVs week for 8 weeks. Review of the clinical record included documented notes that PTVs were not provided on 6/20/24, 7/2/24, 7/9/24, 7/16/24 and 7/18/24, however the notes did not indicate the physician was notified of the missed visits. Review of the Physician ordered Home Health Certification POC, dated 7/31/24 through 9/28/24, included the following orders: *Effective 8/4/24: 1 to 2 PTVs a week for 8 weeks. Review of the clinical record included a documented note that a PTV was not provided on 8/13/24, however the note did not indicate the physician was notified of the missed visit. 2. Patient #7 was admitted to the Agency in February 2024 with a diagnosis of Diabetes Mellitus (a disease that occurs when the body cannot produce or use insulin properly, causing high blood sugars). Review of the Physician ordered Home Health Certification POC, dated 2/2/24 through 4/21/24, included the following orders: *Effective 2/22/24: 1 Skilled Nurse visit (SNV) 1 time a day for 10 weeks. Review of the clinical record included documented notes that SNVs were not provided on 2/2724, 3/21/24, 4/6/24, 4/14/24, 4/18/24 and 421//24, however the notes did not indicate the physician was notified of the missed visits. During an interview on 9/12/24 at 1:55 P.M., the Business Director said staff write interim orders, which are sent to the attending physician, indicating when visits or services were not provided, as ordered in the POC. He said there were no interim orders notifying the physician of the above missed visits for Patient #8 and Patient #7”

“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, staff interview, and policy review, the Home Health Agency failed to ensure that a Registered Nurse (RN) completed a supervisory assessment of the Home Health Aide (HHA) services, at least every 14 days for 1 patient (#2), in a total sample of 8 patients. Findings include: Review of the Agency’s policy entitled, Home Health Aide Supervisory Visits, last revised April 2021, indicated the following, but not limited to: *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 if the patient is receiving skilled services. *Supervisory visits and overall supervision will be documented in the clinical record. Patient #2 was admitted to the Home Health Agency in June 2024 with a diagnosis of Lymphoedema. The Physician’s orders for the certification periods of 6/14/24 - 8/12/24 and 8/13/24 - 10/11/24 indicated that Patient #2 was to receive Home Health Aide services 6 times a week, with the exception of 5 times a week between 8/13/24 - 8/17/24. Review of the clinical record indicated that the Home Health Aide visits were made 6 times a week for the weeks of 8/4/24 through 9/7/24. During this time there were no documented Home Health Aide supervisory visits by the RN, after 8/6/24. During an interview on 9/12/24 at 9:05 A.M., the Business Director said the RN forgot to document her supervisory visit on 8/13/24 when she was working with the Home Health Aide. He also said we dropped the ball since there were no other supervisory visits documented from 8/6/24 through 9/11/24. The expectation is that the RN should have documented her supervisory visit.”