Accentcare Fairview Home Health - West, LLC

“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 interview, the facility failed to report all OASIS data collected in accordance with federal regulations. Total number of records submitted beyond the 30 days was one thousand one hundred seventeen, which equaled 5.10% of the submissions submitted. Findings include: On the HHA Error Summary by Agency report period of 6/1/24 to 7/16/25, the agency had an error code 0f -3330: record submitted late. The description included the submission was more than 30 days after completion on the new record. During an interview on 8/13/25 at 1:06 p.m., the administrator stated the late OASIS submissions were most likely because the company had two restructuring events; one in June of 2024 and one in March of 2025 which affected the OASIS lock process, roles of the staff. and resulted in significant changes in the OASIS process and procedures for all branches. The agency policy Care Planning and Coordination dated 6/10/25, identified the facility will electronically report all OASIS data collected in accordance with federal regulations including encoding individual client assessment within thirty days of completing the assessment and transmitted within thirty days of the Oasis completion.”

“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 interview and document review the facility failed to admit a patient within 48 hours of referral or obtain provider orders to delay admission for 1 of 1 resident (P9) reviewed for admissions. P9’s Home Health Certification and Plan of Care for the period of 4/7/25 to 6/5/25, indicated a start of care date of 2/6/25. P9’s referral dated 1/31/25, indicated P9 was discharged from a care center on 1/31/25 and needed home health services for physical therapy, occupational therapy and home health aide. During an interview on 4/29/25 at 2:03 p.m., intake supervisor (IS) stated P9’s referral was received on 1/31/25 but lacked an admitting doctor or actual orders for home health services. The provider and orders were received on 2/2/25 and was cleared to schedule and complete on 2/2/25. During an interview on 4/30/25 at 10:14 a.m., the territory clinical manager (TCM) stated all new clients are admitted within 48 hours of the time of referral unless there are unforeseen circumstances that would delay the admission. If that did occur then the scheduler would reach out to the licensed practical nurse case support specialist, who would reach out to provider to obtain orders to delay admission. The TCM reviewed P9’s chart and stated P9 was cleared to be admitted as on 2/2/25. There were no orders from the provider to delay admission past the 48 hours. Facility policy Admission of Patients last revised 9/17/24 indicated initial assessment visits would occur within 48 hours of referral, or on the provider ordered start of care date.”

“Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This Condition is not met as evidenced by: Based on the number and/or severity of the deficiencies cited the home health agency (HHA) failed to meet the Condition of Participation: Skilled Professional Services at 42 CFR 484.75. Based on interview and record review, the agency failed to ensure a nurse followed a patient’s plan of care when she changed an indwelling urinary catheter without a physician order and when the nurse changed the indwelling urinary catheter she did not follow acceptable standards of practice for 1 of 1 patient (P1) reviewed for indwelling urine catheter care. The nurse changed P1’s indwelling catheter without assessing proper placement resulting in hospitalization for urethral bleeding and a blood transfusion. According to Lippincott Nursing Journal 2024 titled Inserting an Indwelling Urinary Catheter in a Male Patient indicated to verify the catheter order, using supplies in the kit keep a sterile field, follow the manufactures recommendations to verify catheter balloon integrity, lubricate 6 to 7 inches of the catheter tip…insert catheter tip into the meatus, advance it to 7 to 9 inches or until urine starts draining, then advance it another inch. If you meet any resistance rotate or withdraw the catheter slightly. Holding the catheter in place, inflate the balloon according to the manufacture’s recommendations, gently tug the catheter until you feel resistance. Secure the catheter to the patient’s lower abdomen or upper thigh allowing slack. Provide perineal care, remove gloves, wash hands. Document the date, time catheter size and type and the patient’s response to the procedure. Record the urine amount, odor, color, and consistency. Retrieved from https://journals.lww.com/nursing/citation/2004/07000/inserting_an_indwelling_urinary_catheter_in_a_male.23.aspx. P1’s Home Health Certification and Plan of Care dated 12/21/23 – 2/18/24 indicated P1’s pertinent diagnoses were hypertensive chronic kidney disease, paraplegia (paralysis of the legs and lower body, anemia in chronic kidney disease. P1 required an indwelling catheter. Under the ICD-10 order code the plan of care indicated Code T83.518A M React D/T Other urinary catheter initial encounter (Infection and inflammatory reaction due to urinary catheter, initial encounter). The frequency for skilled nursing visits were one time per week, the orders of disciplines and treatments did not indicate the agency would be completing catheter cares for P1. A physician communication note dated 12/22/23 at 12:53 p.m. indicated Registered nurse (RN)-D spoke to a clinic nurse at P1’s primary care providers office and approved skilled nursing to treat for the services of wound care for an unstageable pressure injury to P1’s coccyx. In addition, the note indicated skilled nursing visits three times a week for two weeks and one visit every other week for wound care and catheter care. The note did not indicate when the catheter change was required, the type or size of the catheter or the balloon size. P1’s visit note dated 1/12/24 completed by RN-A indicated the problematic symptoms to be addressed were wound care and catheter change. P1’s catheter was replaced, patient’s legs kept spasming during change and it was difficult to maintain a sterile procedure. The note did not indicate the type and size of the catheter inserted, the size of the balloon and the amount of sterile water instilled, characteristics of urine: color, amount, odor, patients’ response to the procedure or any education to the patient or the group home staff. P1’s hospital admission documentation dated 1/12/24 indicated the reason for the hospitalization was P1 came to the hospital for urethral bleeding that was caused by an indwelling Foley catheter change. In addition, blood was transfused to replace the loss and the urological team replaced the Foley catheter. Upon interview on 2/12/24 at 10:40 a.m. registered nurse (RN)-B stated she heard from P1’s family member (FM)-A on 1/18/24 that the reason for P1’s hospitalization was caused by the agencies failure to properly insert the urinary catheter. RN-B stated she immediately called RN-A the nurse who inserted the catheter on 1/12/24 to discuss what had occurred on the visit. She stated RN-A would not answer whether she saw urine in the tubing before she inflated in the balloon or not. She stated she explained to RN-A during the telephone conversation that having urine flow before inflating the balloon is the proper method and to even advance the catheter another ½ inch to make 100% sure the tubing is in the bladder and not the urethra. RN-B did not document the conversation with RN-A. Upon interview on 2/12/24 at 10:59 a.m. FM-A stated the past month of his life has been a nightmare since 1/12/24 when RN-A changed P1’s catheter in the group home. FM-A stated P1 was developmentally disabled so he was unable to know if there is a catheter concern and since P1 was a paraplegic he did not have feeling from his waist down, “therefore we need to rely on the professional staff do the cares at the professional level.” FM-A stated he was called on the evening of 1/12/24 from an agency nurse stating P1 needed to be sent to the hospital because he had not had any urine in his bag since the catheter had been changed earlier in the day. He stated licensed practical nurse (LPN)-A explained to him that she was going to change the catheter and when she attempted to remove it P1 started bleeding and she was unable to stop the bleeding. FM-A stated he heard from the hospital that the catheter was inflated in the urethra, and it tore his urethra and that was what caused the bleeding and since P1 was taking Xarelto (a blood thinning medication) he lost a lot of blood quickly requiring blood transfusions in the hospital. Upon interview on 2/12/24 P1 stated “I had to go the hospital. I don’t like the hospital. I was bleeding a lot because the urine tube was put in the wrong place.” Upon interview on 2/12/24 at 2:21 p.m. a group home patient care assistant (PCA)-A stated she worked with P1 the day his catheter was changed. She stated she was not present in his room during the catheter change. She stated around 3:00 p.m. she went to empty P1’s urinary drainage bag and there was no urine in the bag. She stated she checked for kinks in the tubing and then got him out of bed hoping the movement would cause some flow of urine. She stated P1 then ate dinner and the staff attempted to push fluids to see if they could get any urinary output. She stated P1 was in no distress. By 9:00 p.m. on 1/12/24 P1 still did not have any urine output so PCA-A called the group homes on call nurse and was advised to call the Home Health Agencies (HHA) on-call nurse. LPN-A from the HHA made a visit to the group home and was going to assess P1. PCA-A stated LPN-A was having difficulty, so she went into P1’s room to assist, and she found P1 laying in his bed with the protective pad on his bed and his sheets saturated with blood. She stated shortly thereafter emergency medical technicians (EMTs) were called and P1 was taken to the hospital. Upon interview on 2/13/24 at 11:07 a.m. licensed practical nurse (LPN)-A stated she was called out to P1’s group home at approximately 9:00 p.m. on 1/12/24 because P1’s catheter was not draining. She stated when she got there P1 was in no distress, however his catheter drainage bag was “bone dry.” She stated there was no indication of urine in the tubing or the bag. She stated she decided to change his catheter. LPN-A deflated the balloon to remove the tubing and when blood started flowing through the tubing. She stated she measured it to be 75 cc in the drainage bag. She stated she attempted to move P1’s legs, the tubing dislodged, and P1 started bleeding all over the pad on his bed and the sheets. LPN-A tried to elevate his legs and attempted to use ice to slow the bleeding. LPN-A explained to the group home staff and P1 that she was not going to be able to a put new catheter in P1, and he would need to be sent to the hospital. Upon interview on 2/13/24 at 11:44 a.m. RN-C the director nursing completed a chart review for P1 and stated P1 did not have a physician order at the time the catheter was changed on 1/12/24. RN-C stated the nurse case manager, who completed the intake no longer worked at the agency. RN-C stated following P1’s catheter misplacement RN-A had a call with RN-B where she was educated. RN-C was not certain of the education over the phone by RN-B since RN-B no longer worked at the agency. She stated since then, the Administrator has pulled RN-A from any visits requiring catheterization. In addition, the agency had a meeting regarding catheterization protocol procedures along with proper documentation. The agency will be having an in-house meeting for all nursing staff to be retrained and perform catheter insertion and care competencies on 2/22/24 and 2/23/24. Upon interview on 2/13/24 at 1:20 p.m. RN-A stated she visited P1 on 1/12/24 and changed his catheter. She stated that was the first time she had seen him. She recalled when she was placing the catheter his legs were having spasms. She stated she inserted the catheter and could not recall if P1 had any urine return. She stated she might have seen a “flash” of urine but was uncertain. She stated P1’s parents came into P1’s room and distracted RN-A, therefore she could not recall “moment by moment” details of the visit. RN-A stated she was called by a former nurse at the agency and told the catheter had been placed in P1’s urethra requiring him to be hospitalized. She stated on the telephone call RN-B told RN-A that she needs to wait for urine return before she blows up the balloon. RN-A stated she also had a group training at the home health agency (HHA) regarding the policy for inserting a catheter and proper documentation. RN-A attended the meeting online remotely. RN-A has not had a catheter change visit since the incident findings of 1/18/24. RN-A stated she was not told that she was not able to perform catheterization visits until she has a preceptor retrain her but does not have any on her schedule currently. Upon interview on 2/13/24 RN-A stated she was not the case manager for P1 so she would not have been the nurse obtaining the order. She stated the visit status showed catheter change, so she completed the change with the catheter and supplies P1 had on hand on the group home. Upon interview on 2/13/24 at 2:40 p.m. the Administrator stated her expectation is for staff to follow the facility protocol and to wait for urine return for any catheterization. She stated she did inform RN-A that she was not to see any patients for catheterization, however, did not document this in RN-A human resource file. The Administrator stated she is meeting with RN-A again and will be discussing that RN-A is not to do any catheter care until she her competency is checked off by another nurse preceptor. The agency policy titled Urinary and Reproductive: Catheter Indwelling – Care revised 12/2019 indicated the primary care provider orders for indwelling catheters should include: the type of catheter; specific orders are required for specialty catheters, the size of catheter, balloon size, frequency of change, and if the catheter is to be irrigated the solution name and frequency of irrigation, documentation for the patients record following catheterization insertion was to document the type and size of the catheter inserted, the size of the balloon and amount of sterile water instilled, the characteristics of urine: color, amount, odor, the patient’s response to the procedure, instructions given to the patient/caregiver, communication with primary care provider if any, and the frequency of the catheter change. The agency Assessment Performance criteria, dated for Urinary catheter insertion undated indicated for male indwelling catheter staff is gently insert the catheter six to seven inches into the urinary meatus, advancing two to three inches until the flow of urine begins.”

“Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This Element is not met as evidenced by: Based on interview and record review the home health agency (HHA) failed to ensure an investigation was conducted and record of any findings including a resolution for 1 of 1 patient (P2) reviewed for nursing services. P2’s client coordination note report dated 7/25/22 indicated staff was to call daughter to set-up all HHA appointments. Agency Event Summary report review dated 3/28/23 – 1/18/24 did not indicate a grievance was documented, an investigation completed, or a resolution plan. P2’s Home Health Certification and plan of care dated 8/5/23 – 10/3/23 indicated P2’s pertinent diagnoses were benign prostatic hyperplasia with lower urinary tract symptoms (enlarged prostate which can cause urinary difficulty). History of urinary tract infections. P2’s mental status was oriented and forgetful. P2 required an indwelling urinary Foley catheter. P2’s skilled nursing order was to change urinary catheter once a month and as needed. P2’s care coordination follow-up note dated 8/25/23 at 11:53 a.m. indicated family member (FM)-B called the HHA with a grievance indicating that P2’s family had requested all appointments be schedule through P2’s daughter. P2 was seen on by agency staff on 8/25/23 and he started having symptoms of a urinary tract infection (UTI). P2 was brought to the emergency department (ED). FM-B told the ED that P2’s catheter was due to be changed, FM-B was not aware that the agency had been changed the catheter on 8/25/23. P2’s care coordination follow-up note dated 9/6/23 at 10:18 a.m. by RN-E indicated she spoke with FM-B a week ago and FM-B stated the agency nurses did not contact her and she has specifically requested only two of the agency nurses to perform the catheter change on P2 and a different nurse went out and changed the catheter. RN-E informed FM-B that the agency cannot guarantee a specific nurse. FM-B decided to change to a different agency. P2’s care coordination follow-up noted by RN-E indicated FM-B was requesting a different agency for P2 upon discharge from the transitional care unit (TCU). Upon interview on 2/12/24 at 9:10 a.m. FM-B stated P2 was a long-time patient of the HHA and in 08/2022 FM-B put into place that the agency was to call her before a nursing visit because P2 was forgetful and gets feisty with some of the nurses. FM-B wanted to be present at the visit especially if a new nurse was going to be visiting P2. FM-B stated P2 had a nursing visit on 8/25/23 and the daughter was not informed of the visit. The day following visit along with the catheter change P2 was vomiting and was not having urinary drainage. P2’s son took him to the hospital and P2 was admitted with cystitis. When P2 arrived at the hospital the family was unaware he had a catheter change the day before, therefor “we gave the hospital misinformation because we were not notified of the HHA visit.” Upon interview on 2/14/24 at 2:40 p.m. the Administrator stated the staff member who took the complaint no longer works at the agency. After reaching the coordination notes in P2’s chart she stated that the agency should have completed an event summary and investigated the grievance. A grievance policy was requested however none was received.”