Advisacare Solutions of Nevada, 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 record review and interview, the Home Health Agency (HHA) failed to ensure the timely submission of OASIS (Outcome and Assessment Information Set) to IQIES (Internet Quality and Improvement and Evaluation System). The failure had the potential to affect all 53 patients receiving services from the HHA who require evaluation and care. Findings include: Review of the undated agency’s policy titled, OASIS Completion & Data Processing, documented “Once OASIS assessment is completed it should be reviewed and encoded into the computer as soon as possible. All OASIS assessments must be transmitted to the CMS [Centers of Medicare and Medicaid] system no later than 30 days after completion of the assessment…” The agency’s OASIS submission data since May 2021 was reviewed for timely transmission to IQIES. The data revealed late transmissions over the state’s threshold of 10.0% per quarter. This resulted in an error code of -3330 (late submission). During an interview on 05/29/25 at 10:55 AM, the Director of Clinical Services (DCS) confirmed there were issues with staffing. The DCS also furnished an undated e-mail from the Administrator that read, “OASIS transmissions were late related to late processing of OASIS items -Late RN [Registered Nurse] submissions for review -Late RN returning for corrections completed -Late during COVID due to lack of staff to complete state submissions -Previous Administrator/ Clinical manager not completing follow through with staff -Per Diem staff that are not as dedicated as full time staff would be.””

“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, interview, and policy review, the Home Health Agency (HHA) failed to ensure care was initiated timely after referral to the agency for one of seven sampled patients (Patient (P) 5) reviewed during the survey. This deficient practice had the potential to affect all 54 patients receiving services from the HHA. Findings include: Review of the agency’s undated policy titled, Referral and Acceptance of Patients Policy, indicated “A nurse or appropriate staff member will evaluate patients within 24 – 48 hours of referral or discharge from a facility unless otherwise ordered by the physician.” Review of P5’s medical record revealed the patient was referred to the agency on 03/27/25 for Physical Therapy services after partial knee replacement surgery. The record revealed services were not initiated by the agency until 04/04/25 when P5 was seen by an agency nurse for evaluation and initiation of ordered care. There was nothing found in the record to indicate a rationale for the delay in P5’s initiation of care. During an interview on 05/29/25 at 10:46 AM, the Director of Clinical Services (DCS) confirmed P5 was not seen by agency staff to initiate services until seven days after her referral to the agency for services. The DCS was not able to explain why there was a seven-day delay in initiation of care for P5 and stated patients were expected to be seen for the initiation of services within 24-48 hours after referral to the Agency.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, record review, interview, and policy review, the Home Health Agency (HHA) failed to ensure the Registered Nurse (RN) conducted a medication reconciliation during homecare visits for one of seven sampled patients (Patient (P) 6) reviewed for medication reconciliation. This deficient practice had the potential to affect all 54 patients receiving services from the HHA. Findings include: Review of the agency’s undated policy titled, Medication Management Policy, indicated “The medication profile will be updated when there are any medication changes.” Observation during a homecare visit performed by Certified Nursing Assistant (CNA) 1 on 05/28/25 at 8:00 AM, revealed that P6’s Medication List, did not accurately reflect the medications being administered to the patient in home. Medications indicated in P6’s EMR physician’s orders included carbidopa-levodopa (a medication used to control symptoms of Parkinson’s disease) 25-250 milligrams (MG) three times daily, clopidogrel (a blood thinning medication) 75 MG daily, and quetiapine (an antipsychotic medication) 25 MG every night. The carbidopa-levodopa, clopidogrel, and quetiapine were not located in R6’s home during the medication review. During an interview on 0528/25 at 8:25 AM, P6 stated was no longer taking the carbidopa-levodopa, clopidogrel, or quetiapine. P6 stated had stopped taking those medications a while ago. During an interview on 05/29/25 at 10:46 AM, the Director of Clinical Services (DCS) confirmed P6 was receiving ordered weekly skilled nursing visits and indicated medications were expected to be reconciled by the nurse at every visit. The DCS stated the expectation was that the medications being administered to residents in their homes should match the agency’s medication order set.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview, record review, and policy review, the home health agency (HHA) failed to ensure home health services were provided as ordered for two of seven sampled patients (Patient (P) 3 and P6). This deficient practice had the potential to cause patient care needs not be met and could affect all patients cared for by the agency. 2. Review of P6’s electronic medical record revealed the patient’s CMS 485 (Home Health Certification and Plan of Care), dated 04/30/25 and initiated after the patient’s hospitalization, revealed an order for MSW (Medical Social Worker): Veteran needs MSW assist for more ADL Activities of Daily Living) help. Nothing could be located in P6’s record to indicate the patient had been seen by MSW or a visit by the MSW had been scheduled related to this order. During an interview on 05/29/25 at 10:46 AM, the Director of Clinical Services (DCS) confirmed P6 had not been seen by a Medical Social Worker related to the 04/30/25 return from hospital order. The DCS stated patients referred to MSW were expected to be seen timely to ensure appropriate services were being provided. Findings include: Review of the agency’s undated policy titled, Professional and Ancillary Services, indicated “…Occupational Therapy: The Agency shall provide occupational therapy by qualified occupational therapist or occupational assistant under the supervision of an occupational therapist in accordance with the physician’s written orders…The Agency shall provide social services by a qualified social worker…” 1.Review of P3’s Home Health Certification and Plan of Care, revealed a start of care (SOC) date of 04/10/25 with diagnoses including acute and chronic respiratory failure with hypoxia. Review of P3’s physician orders, dated 04/28/25, revealed, “OT [Occupational Therapist] Evaluation…” Review of the Skilled Nurse (SN) visit notes, revealed no evaluation performed by OT. During an interview on 05/29/25 at 9:20 AM, the Director of Clinical Services (DCS) was asked about the OT evaluation. The DCS stated if it was ordered there should have been an authorization request. “I don’t think it has come in yet.” During an interview on 05/29/25 at 9:35 AM, the Intake Coordinator (IC) was asked if there was an authorization for the OT request. The IC stated once a request for an evaluation was made, then an authorization was requested. The IC was asked to look and see if there was authorization for OT. The IC brought in an authorization form that included an authorization being approved for OT on 04/08/25.”

“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 review, interview, and policy review, the Home Health Agency (HHA) failed to ensure physician’s orders/plan of care were reviewed and signed timely by the Patient’s physician for five of seven sampled patients (Patients (P) 6, P1, P2, P3, and P4) reviewed during the survey. This deficient practice had the potential to affect all 54 patients receiving services from the HHA. Findings include: Review of the agency’s undated policy titled, Medical Supervision Policy documented, “The attending physician will provide complete and accurate information about the patient and shall sign and date in the timeframe designated by the Agency, a written plan of treatment and subsequent change orders.” Review of P6’s electronic medical record revealed the patient’s CMS (Centers for Medicare and Medicaid Services) 485 (Home Health Certification and Plan of Care) was most recently initiated for continuation of home health services for the 60-day period of 04/14/25 through 06/12/25. The document indicated P6 was to receive skilled nursing and physical therapy services throughout the certification period. Review of the record revealed P6 was receiving services according to the patient’s plan of care (CMS 485), however there was no evidence to show the document had been reviewed and signed by the patient’s physician to validate the patient’s need for services and establish orders for the patient to receive the services. During an interview on 05/29/25 at 10:46 AM, the Director of Clinical Services (DCS) confirmed the CMS 485 form had not yet been signed by P6’s physician. The DCS confirmed CMS 485 was expected to be signed by each patient’s physician within 30 days of the initiation or continuation of services for each 60-day certification period. The DCS stated physicians were often difficult to reach to ensure review and implementation of valid and current orders for patient services. 2. Review of P1’s Home Health Certification and Plan of Care revealed a start of care (SOC) date of 06/22/24. The form was digitally signed by the nurse on 07/02/24. The form was not signed by the physician until 08/18/24, which was 47 days later. 3. Review of P2’s Home Health Certification and Plan of Care revealed a SOC of 08/10/24. The form was digitally signed by the nurse on 07/02/24. The form was not signed by the physician until 10/15/24, which was 64 days later. 4. Review of P3’s Home Health Certification and Plan of Care revealed a SOC of 04/10/25. The form was digitally signed by the nurse on 04/10/25. The form was not signed by the physician, which was 49 days later at the time of the survey. 5. Review of P4’s Home Health Certification and Plan of Care revealed a SOC date of 01/26/25, and a recertification period of 03/27/25- 05/25/25. The form was digitally signed by the nurse on 03/26/25. The form was not signed by the physician until 05/12/25, which was 47 days later. During an interview on 05/29/25 at 10:56 AM, the Director of Clinical Services (DCS) stated, “The form should be signed and returned within 30 days. Technically they are the orders we are to follow.””