Acclaim Home Health Care, Inc.

“Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms “facility” or “facilities” in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: Based on staff interview, the agency failed to meet the §483.475 (Emergency Preparedness) requirements for Home Health Agencies and did not establish and maintain a comprehensive Emergency Preparedness (EP) program that met all of the standards specified within the Conditions of Participation for the EP program. Findings include: During an interview on 5/30/24 at 11:15 A.M., the Director of Payroll and Billing said the agency was sold in 7/2023 and the previous owner took all the policies and procedures including the Emergency Preparedness Program. The agency has not established an Emergency Preparedness Program since the agency was sold including the following required elements: - Written policies and procedures based on the agency’s and community-based risk assessment, utilizing an all-hazards approach. - An EP training program including initial and yearly staff training and participation in emergency preparedness drills. - A process to ensure annual exercises were conducted to test the emergency plan.”

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on staff interview, the agency failed to develop, establish and maintain a comprehensive emergency preparedness program to comply with all applicable federal, state and local emergency preparedness requirements. Findings include: The Director of Payroll and Billing was interviewed on 5/30/24 at 11:15 A.M. and said she was unable to locate the agency’s comprehensive emergency preparedness program. She stated the previous owner took the Emergency Preparedness binder and the agency did not develop a new plan.”

“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 interview, the agency failed to develop and maintain an emergency preparedness plan that included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings include: During an interview on 5/30/24 at 11:15 A.M., the Director of Payroll and Billing said she was unable to locate a completed all hazards risk assessment.”

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on staff interview, the agency failed to implement an emergency preparedness training program for new employee orientation and every 2 years thereafter as required. Findings include: During an interview with the Director of Payroll and Billing on 5/30/21 at 11:15 A.M., she said she was unable to provide any evidence of emergency preparedness training for employees.”

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on interview, the agency failed to ensure that annual exercises were conducted to test the emergency plan. Findings include: During an interview with the Director of Payroll and Billing on 5/30/24 at 11:15 A.M., she said she could not locate any evidence of annual exercises to test their emergency plan.”

“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 in 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. Findings Include: Review of the facility’s 2023 Home Health Agency Error Summary Report indicated that 21 of 859 Oasis Assessments processed were submitted more than 30 days after completion. During an interview on 5/30/24 at 1:06 P.M., the Director of Payroll and Billing said that the previous owner had been submitting the OASIS Assessments through July 2023. She said she was aware that some of the assessments were submitted late.”

“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 record review and interview the agency failed to ensure the plan of care was followed for 1 Patient (#4), in a total sample of 7 patients. Findings include: Patient #4 was admitted to the agency in 1/2024 with a diagnosis of diabetes mellitus type 2. Review of the Home Health Certification and Plan of Care, dated 3/1/24 - 4/29/24, indicated the following: Skilled Nursing Visits 5 times a week for 60 days and Home Health Aide visits 3 times a week for 60 days. Review of Patient #4’s record indicated the following visits were not conducted as ordered: Week of 3/3/24 - 3/9/24: 2 of 3 physician ordered home health aide visits were conducted. Week of 3/17/24 - 3/23/24: 2 of 3 physician ordered home health aide visits were conducted. Week of 3/31/24 - 4/6/24: 2 of 3 physician ordered home health aide visits were conducted and 4 of 5 ordered skilled nursing visits were conducted. Week of 4/7/24 - 4/13/24: 2 of 3 physician ordered home health aide visits were conducted and 4 of 5 ordered skilled nursing visits were conducted. Week of 4/14/24 - 4/20/24: 2 of 3 physician ordered home health aide visits were conducted. Week of 4/21/24 - 4/27/24: 2 of 3 physician ordered home health aide visits were conducted. Review of the Home Health Certification and Plan of Care, dated 4/30/24 - 6/28/24, indicated the following: Skilled Nursing Visits 5x a week for 60 days and Home Health Aide visits 3 times a week for 60 days. Review of Patient #4’s record indicated the following visits were not conducted as ordered: Week of 4/28/24 - 5/4/24: 2 of 3 physician ordered home health aide visits and 4 of 5 skilled nursing visits were conducted. Week of 5/5/24 - 5/11/24: 2 of 3 physician ordered home health aide visits and 4 of 5 ordered skilled nursing visits were conducted. Week of 5/12/24 - 5/18/24: 2 of 3 physician ordered home health visits were conducted. Week of 5/19/24 - 5/25/24: 3 of 5 physician ordered skilled nursing visits were conducted. There was no documentation in the record as to why there were missed visits. During an interview with the Director of Payroll and Billing on 5/30/24 at 10:15 A.M. she said if a skilled nursing visit is missed, there should be a missed visit note in the record. If a home health visit is missed it should be documented on the home health aide weekly sheet.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure complete and appropriately authenticated, dated, and timed documentation. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. Findings include: Patient #2 was admitted to the agency in December 2023 with a diagnosis of Chronic Obstructive Pulmonary Disease requiring skilled care. Review of an Occupational Therapy (OT) order, dated 2/15/24, indicated Skilled OT services 1-2x/week for the remainder of the certification period ending 2/19/24. Further review of this order indicated it had not been signed and dated by the physician. During an interview on 5/30/24 at 11:45 A.M., the Director of Payroll and Billing said the OT order should have been faxed to the physician for a signature and had not been completed as required.”

“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 staff interview, the agency failed to ensure a registered nurse conducted an initial assessment visit to determine the immediate care and support needs of the patient 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, for one Patient (#2) out of a total sample of 7 patients. Findings include: Patient #2 was admitted to the agency in December 2023 with a diagnosis of Chronic Obstructive Pulmonary Disease. Review of the clinical record indicated the patient was referred to the agency on 12/18/23, and the initial assessment was completed on 12/22/23 by a registered nurse (RN). During an interview on 5/30/24 at 12:15 P.M., RN #1 said she attempted to see the patient on 12/21/23, but he/she refused a visit that day. She said the initial assessment was completed the following day on 12/22/23. She said the assessment was not done within 48 hours of referral as required.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure staff made an update to the comprehensive assessment including a discharge summary and submission of a discharge Outcome and Assessment Information Set (OASIS) to Centers for Medicare and Medicaid Services (CMS) for one Patient (#2) out of total sample of 7 patients. Findings include: Review of the facility’s policy entitled, Patient Acceptance, Transfer and Discharge, dated December 2006, included the following: -All Patient accepted for care under Acclaim Home Health Care Services will receive a comprehensive assessment according to CMS Guidelines, and all documentation will be maintained from Admission to Discharge according to Acclaim Home Health Policies and Procedures. -On discharge date, a discharge summary as well as a discharge notification is completed. The discharge summary is filed in the record. Review of the facility’s policy, entitled Oasis Management, dated November 2007, included the following: -Additional assessment for Transfer OASIS, Resumption of Care, Follow-up or Discharge will be done by appropriate disciplines. -All OASIS must be completed within 24 hours. Patient #2 was admitted to the agency in December 2023 with a diagnosis of Chronic Obstructive Pulmonary Disease requiring skilled care. Review of the clinical record indicated the patient had a 60 Recertification and Plan of Care completed on 2/16/24 for the following 60 day certification period (2/20/24 through 4/19/24). Review of the Admission/Discharge Report provided to the surveyor on 5/29/24, indicated that Patient #2 had been discharged on 2/19/24. Review of a Missed Visit Skilled Nursing Note, dated 2/20/24, indicated Patient #2 was being seen by another agency for service. The note indicated the clinic manager was notified by phone. Further review of the record indicated an update to the comprehensive assessment including a discharge OASIS assessment had been completed. During an interview on 5/30/24 at 12:30 P.M., the Director of Payroll and Billing said the agency had to discharge the patient from their services as he/she was being seen by another home care agency. After reviewing the medical record, she said there was not an update made to the comprehensive assessment, including completing a discharge OASIS. She said it was not completed as the agency thought it would interfere with the new agency’s admission OASIS.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure a completed discharge summary was sent to the primary care practitioner after discharge from the Home Health Agency (HHA) within 5 business days of the patient’s discharge, for one Patient (#2), out of a total sample of 7 patients. Findings include: Patient #2 was admitted to the agency in December 2023 with a diagnosis of Chronic Obstructive Pulmonary Disease requiring skilled care. Review of the clinical record indicated that Patient # 2 had a Resumption of Care Outcome and Assessment Information Set (ROC-OASIS) completed on 2/12/24 after returning home from a stay at a Skilled Nursing Facility (SNF). Review of the Admission/Discharge Report provided to the surveyor on 5/29/24, indicated that Patient #2 had been discharged on 2/19/24. Review of a Missed Visit Skilled Nursing Note, dated 2/20/24, indicated Patient #2 was being seen by another agency for service. The note indicated the clinic manager was notified by phone. Further review of the record indicated a discharge summary had not been completed and forwarded to the attending physician. During an interview on 5/30/24 at 12:30 P.M., the Director of Payroll and Billing said staff discovered that Patient #2 was being followed by a different home care agency after returning home from the SNF. She said, after reviewing the medical record, that there was not a discharge summary completed and forwarded to the physician as required.”