Dependable Home Health of Nevada 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 agency failed to electronically transmit each completed OASIS assessment within 30 days of completing the assessment of the beneficiary for 12 of 13 quarters since its initial survey on 8/23/2020 and 3 of 3 quarters since the agency withdrew to the state authority effective 8/12/2023. Findings Include: According to the state’s OASIS Education Coordinator in the pre-survey report, the agency was out of compliance due to late transmission of OASIS for 12 of 13 quarters since the initial certification survey on 8/23/2020 and 3 of 3 quarters, since the agency withdrew to the state authority effective 8/12/2023. The assessments submitted late for the last four quarters varied from a low of 16.8% to a high of 63.4% of all quarterly submissions. On 8/27/2024 in the afternoon, the Director of Clinical Operations confirmed the findings and indicated the agency was no longer using a third party contractor to submit assessments and submissions should improve going forward.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included an order for physical therapy evaluation for 1 of 18 patients (Patient #15). Findings include: Patient #15 On On 8/13/2024, the agency admitted Patient #15 with hypertensive heart and chronic kidney disease with heart failure. On 8/13/2024, the plan of care revealed numerous physical therapy interventions and goals for the patient. On 8/14/2024, 8/16/2024 and 8/19/2024, physical therapy visits were conducted and documented in the clinical record. The plan of care lacked documented evidence a physician ordered a physical therapy evaluation. On 8/27/2024 in the afternoon, the Director of Clinical Operations indicated all disciplines should be included in the plan of care if ordered at the start of care.”

“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 record review, interview and policy review, the agency failed to ensure skilled nursing visits and secondary discipline’s visits were conducted as ordered or in a timely manner for 8 of 17 patients (Patient #1, #6, #8, #9, #10, #11, #13 and #17), and failed to ensure an ordered Foley catheter balloon was filled with the corresponding volume of sterile water for 1 of 17 patients (Patient #16). Findings include: Patient #1 On 6/29/2023, the agency admitted Patient #1 with hypertensive heart and chronic kidney disease with heart failure. On 7/11/2023, the agency transferred the patient to acute care. On 8/17/2023, the agency resumed the patient’s home health care. A physician ordered skilled nursing visits weekly for 2 weeks and evaluations for physical therapy, occupational therapy and social services. There was no documented evidence the orders were changed, discontinued or otherwise modified. There were no missed visits documented. On 8/26/2023, the agency discharged the patient. The clinical record lacked documented evidence any visits were conducted or documented. The agency asked the patient to submit for private pay until insurance was approved and then did no visits and discharged the patient per request for declining private pay. On 8/28/2024 in the afternoon, the Director of Clinical Operations confirmed the agency could not obtain authorization. Patient #6 On 4/20/2023, the agency admitted Patient #6 with cholecystitis. The agency certified Patient #6 from 4/20/2023 to 6/18/2023. On 4/20/2023, the plan of care revealed a physician ordered physical therapy 1 visit every other day for 4 days. The clinical record lacked documented evidence any physical therapy visits were conducted or documented. The clinical record lacked documented evidence of a physician order to cancel or discontinue physical therapy visits. On 8/27/2023 at 3:20 PM, the Director of Clinical Operations indicated the orders were on the plan of care but were not addressed. Patient #8 On 8/31/2023, the agency admitted Patient #8 with open wound of the right lower leg. The agency certified Patient #8 from 8/31/2023 through 10/29/2023. On 8/31/2023, the plan of care revealed a physician ordered skilled nursing visits twice weekly after the start of care visit. During the entire certification period, a wound care service conducted weekly home visits, ordering agency skilled nursing visits twice weekly throughout the remainder of the certification period. Clinical record review revealed the following skilled nursing visit frequency conducted and documented: Week of 9/17/2023 to 9/23/2023 : no skilled nursing visits. Week of 9/24/2023 to 9/30/2023 : 1 skilled nursing visit on 9/28/2023. Week of 10/1/2023 to 10/7/2023 : 1 skilled nursing visit on 10/5/2023. Week of 10/22/2023 to 10/28/2023 : 1 skilled nursing visit on 10/26/2023. The clinical record lacked documented evidence of an order to change, discontinue or otherwise modify the visit frequency. The clinical record lacked documented evidence of missed visits for the aforementioned weeks. On 8/28/2024 in the afternoon, the Director of Clinical Operations confirmed the lack of aforementioned documentation. Patient #9 On 12/1/2023, the agency admitted Patient #9 with urostomy. The agency certified Patient #9 from 12/1/2023 through 1/29/2024. On 12/1/2023, the plan of care revealed a physician ordered home health aide visits once the first week and then three times weekly for eight weeks. The clinical record lacked documented evidence of any home health aide visits 12/1-2/2023, which was the first week. The clinical record revealed two documented missed visits dated 12/13/2023 and 12/16/2023. The clinical record lacked documented evidence of the ordered third visit for the week of 12/10-16/2023. The clinical record lacked documented evidence of a physician order changing, discontinuing or otherwise modifying either order above. On 8/27/2024 in the afternoon, the Director of Clinical Operations verbalized the third visit was not addressed. Patient #10 On 7/25/2023, the agency admitted Patient #10 with left knee osteoarthritis. The agency certified Patient #10 from 7/25/2023 through 9/22/2023. On 7/30/2023, the agency transferred the patient to acute care. On 8/15/2023, the agency resumed home health care services. On 8/15/2023, the plan of care revealed a physician ordered weekly skilled nursing visits. The clinical record lacked documented evidence a skilled nursing visit was conducted and documented for the week of 9/10-16/2023. The clinical record lacked documented evidence the order was changed, discontinued or otherwise modified. On 8/15/2023, the plan of care revealed a physician ordered an occupational therapy evaluation. The clinical record lacked documented evidence the occupational therapy evaluation was conducted and documented. The clinical record lacked documented evidence the order was changed, discontinued or otherwise modified. On 8/27/2024 at 3:00 PM, the Director of Clinical Operations verbalized the above skilled nursing visit and occupational therapy evaluation were not addressed. Patient #11 On 8/13/2024, the agency admitted Patient #11 with pressure ulcer of right buttock. On 8/13/2024, the plan of care revealed a physician ordered an occupational therapy evaluation. On 8/19/2024, a therapist conducted and documented an occupational therapy evaluation. On 8/27/2024 in the afternoon, the Director of Clinical Operations indicated the agency had to wait for insurance authorization for the occupational therapy evaluation. The Director of Clinical Operations verbalized it was reasonable for patients to wait up to a week, but there was no agency policy governing the timeliness of initial evaluations by secondary disciplines. The agency was not accountable for timeliness of initial evaluations. Patient #13 On 10/19/2023, the agency admitted Patient #13 with stage 4 pressure ulcer of left hip. The agency certified Patient #13 from 10/19/2023 to 12/17/2023. The agency recertified the patient from 12/18/2023 to 2/15/2024. The plan of care revealed a physician ordered twice weekly skilled nurse visits. On 12/27/2023 and 1/1/2024, a Registered Nurse documented missed visits, writing scheduling conflict for both scheduled visits. The clinical record lacked documented evidence of any additional attempts to conduct ordered skilled nurse visits for those weeks. The missed visit excuse did not specify whether the scheduling conflict was because of the nurse or the patient. The clinical record lacked documented evidence of a physician order to change, discontinue or otherwise modify the skilled nurse frequency. On 12/22/2023, an occupational therapist conducted and documented an ordered evaluation resulting in weekly occupational therapy visits for five weeks. The clinical record lacked documented evidence any occupational therapy visits were conducted or documented for the week of 12/24/2023 to 12/30/2023 and from 12/31/2023 to 1/6/2024. The clinical record lacked documented evidence of a physician order to cancel or discontinue or otherwise modify occupational therapy visits. On 8/27/2023 at 3:20 PM, the Director of Clinical Operations indicated the agency should document whether the missed visit was a staffing issue or a patient communication issue, and the agency did not receive insurance authorization at the time of the ordered occupational therapy visits. Patient #16 On 7/18/2023, the agency admitted Patient #16 with adjustment of urinary device. On 7/18/2023, the plan of care revealed a physician ordered skilled nurse visits once every 3 weeks for 9 weeks. On 7/18/2023, the plan of care specified for the skilled nurse to use a Foley catheter of size 18 French with a 10 milliliter balloon. On 8/12/2023 and 8/28/2023, a Licensed Practical Nurse documented the Foley catheter changes as inflating the balloon with 30 milliliters of sterile water. On 8/27/2024 in the afternoon, the Director of Clinical Operations verbalized the nurse should use the sterile water to inflate the balloon to the corresponding volume size of the balloon, (which was 10 milliliters in this case). Patient #17 On 7/17/2024, the agency admitted Patient #17 with acute respiratory failure with hypoxia. On 7/17/2024, the plan of care revealed a physician ordered physical therapy and occupational therapy evaluations. On 7/18/2024, the patient was transferred to acute care. On 7/23/2024, the agency resumed home health care, and a physician again ordered physical and occupational therapy evaluations. On 7/30/2024, a physical therapist conducted and documented a physical therapy evaluation (7 days). On 7/31/2024, an occupational therapist conducted and documented an occupational therapy evaluation (8 days). On 8/27/2024 in the afternoon, the Director of Clinical Operations indicated the agency considered 7 days a reasonable time to allow to conduct an initial evaluation for secondary disciplines. The Director of Clinical Operations was asked for its policy regarding timeliness of initial evaluations for secondary disciplines. The agency lacked documented evidence of a policy addressing the timeliness of initial evaluations for secondary disciplines and lacked Governing Body evidence of any kind referencing 7 days as an approved or reasonable standard. Incident #102003”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure notification was made with a change in condition for 1 of 18 patients (Patient #2). Findings include: Patient #2 On 6/9/2023, the agency admitted Patient #2 with diabetes mellitus and diabetic chronic kidney disease. On 6/9/2023, the plan of care revealed a physician ordered skilled nursing visits weekly and to notify physician of fasting blood sugars greater than 200. On 6/13/2023, the agency transferred Patient #2 to acute care for unstable blood sugar. On 6/23/2023, the agency resumed home health care with weekly skilled nursing visits. On 6/29/2023, the documented skilled nursing visit lacked documented evidence of a blood sugar. On 7/4/2023 and 7/11/2023, the skilled nursing visits included documented fasting blood sugars greater than 200. The clinical record lacked documented evidence a physician was notified as per the plan of care. On 8/28/2024 in the afternoon, the Director of Clinical Operations verbalized a physician should have been notified as per the plan of care. Procedure #3 of the Monitoring Patient’s Response/Reporting To Physician (4-012.1), the patient’s physician will be contacted on the same day when any of the following occur: A. Significant changes in the patient’s condition.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure a current, revised medication profile for 1 of 18 patients (Patient #7). Findings include: Patient #7 On 7/4/2024, the agency admitted Patient #7 with laceration without foreign body. The agency certified the patient from 7/4/2024 through 9/1/2024. On 8/21/2024 in the late afternoon, a home visit was conducted. At the end of the home visit, a medication reconciliation was conducted with the son of the patient. A number of supplements did not appear on the medication profile provided by the agency for the home visit, including Vitamin B12, Vitamin C and Zinc. In addition, the patient had a newly filled container of Hydrocodone 5/325 milligrams dated 8/5/2024. The son indicated it was twice daily, but the label said every 8 hours. At the conclusion of the visit, the Licensed Practical Nurse was informed of medication discrepancies between what the patient had and the medication profile provided. On 8/28/2024, another medication profile was obtained which showed the same inaccurate copy the agency provided for the home visit on 8/21/2024.”

“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 and interview, the agency failed to ensure it provided home health aide supervision on site at least once every 14 days for 1 of 18 patients (Patient #9). Findings include: Patient #9 On 12/1/2023, the agency admitted Patient #9 with an ostomy. The agency certified Patient #9 from 12/1/2023 through 1/29/2024. On 12/1/2023, the plan of care revealed a physician ordered home health aide visits once the first week and then three times weekly for eight weeks. Home health aide supervision was conducted and documented on 12/13/2023 and 1/9/2024. The clinical record lacked documented evidence the agency conducted and documented home health aide supervision the week of 12/24-30/2023. On 8/27/2024 in the afternoon, the Director of Clinical Operations indicated there should have been home health supervision completed during the week of 12/24-30/2023.”

“Coordinate patient care CFR(s): 484.105(c)(2) Coordinating patient care, This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure it coordinated patient care regarding wound care for 1 of 18 patients (Patient #13). Findings include: Patient #13 On 10/19/2023, the agency admitted Patient #13 with Stage 4 pressure ulcer of left hip. The agency certified the patient from 10/19/2023 to 12/17/2023. The agency recertified the patient from 12/18/2023 to 2/15/2024. On 2/1/2024, the agency resumed care of the patient following hospitalization. On 2/1/2024, the plan of care revealed a physician ordered twice weekly skilled nursing visits for wound care. On 2/1/2024, the plan of care revealed a physician ordered wound vac dressing changes. On 2/3/2024, The agency documented a missed skilled nursing visit. On 2/8/2024, a Registered Nurse conducted and documented a skilled nursing visit. The Registered Nurse documented the following: The third party wound care company would not issue wound care orders until it saw the patient. The company was reminded it had not seen the patient for a week already with a wound vac. The spokesperson indicated the wound care company would visit the patient on 2/12/2024. The Director of Clinical Operations advised the Registered Nurse to do no wound care despite the plan of care order in place. Instead, the Registered Nurse instructed patient/caregiver to contact the agency or physician if something went wrong with the wound vac. On 2/10/2024, a Registered Nurse documented a missed visit form, regarding no wound care orders until the wound care company saw the patient on 2/13/2024. On 2/12/2024, a Licensed Practical Nurse conducted and documented a skilled nurse visit, documenting wound care was done. The skilled nurse visit lacked documented evidence of what wound care was performed. The clinical record lacked documented evidence the wound care company saw the patient after the resumption of care dated 2/1/2024. The clinical record lacked documented evidence of a communication note as to why. The clinical record lacked documented evidence of any wound care order issued from the wound care company. The agency discharged the patient without any further visits claiming “patient did not answer the door”. On 8/27/2024 in the afternoon, the Director of Clinical Operations confirmed there was no documentation or response from the wound care company and why the patient was not evaluated or another wound care order issued. There was no reason or explanation as to why the Licensed Practical Nurse performed either wound vac change (as ordered with the resumption of care on 2/1/2024) on 2/12/2024 that the Registered Nurse did not do on 2/8/2024, or otherwise what new wound care the Licensed Practical Nurse performed but did not document on 2/12/2024.”

“Goals in the patient’s plans of care CFR(s): 484.110(a)(3) Goals in the patient’s plans of care and the patient’s progress toward achieving them; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient goals were synonymous with the intervention performed during a skilled nursing visit for 1 of 18 patients (Patient #12). Findings include: Patient #12 On 9/29/2023, the agency admitted Patient #12. The agency certified Patient #12 from 9/29/2023 through 11/27/2023. On 9/29/2023, the plan of care revealed a physician ordered a wound vac dressing and the goals and interventions reflected that. On 11/18/2023, a Licensed Practical Nurse conducted and documented a skilled nursing visit. The Licensed Practical Nurse documented performing wound care as follows: Nurse cleansed the wound with wound cleanser and pat dry. Nurse applied xeroform, kerlix and coban. An accompanying unmet goal included, the patient and caregiver being knowledgeable regarding care of the wound vac dressing, which was not the dressing performed. The goals were disassociated from the actual care performed and no longer applied and were not modified. Under the intervention performed section, the Licensed practical Nurse documented performing the wound vac dressing order. The clinical record lacked documented evidence of a wound care order which included using xeroform at the time of the skilled nursing visit documented on 11/18/2023. On 11/22/2023, the same Licensed Practical Nurse conducted and documented a skilled nursing visit. The Licensed Practical Nurse documented performing wound care as follows: Nurse cleansed the wound with wound cleanser and pat dry. Nurse applied xeroform, kerlix and coban. An accompanying unmet goal included, the patient and caregiver being knowledgeable regarding care of the wound vac dressing, which was not the dressing performed. The goals were disassociated from the actual care performed and no longer applied and were not modified. The clinical record lacked documented evidence of a wound care order which included using xeroform at the time of the skilled nursing visit documented on 11/22/2023. In addition, the Licensed Practical Nurse documented a conversation with the Podiatrist’s office, reminding it to fax the current wound care order, so the agency would have the updated order. On 11/27/2023, the agency recertified the patient from 11/28/2023 to 1/26/2024. On 11/28/2023, the plan of care revealed the new wound care order with xeroform with synonymous goals. On 8/27/2024 in the afternoon, the Director of Clinical Operations indicated the order should be obtained at the time of the change in wound care. Goals should reflect the current care being performed.”