New Era Home Healthcare Services Inc.

“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 observation, interview and record reviews, the agency failed to ensure all patients received home health services as ordered in the individualized POC. In 2 (Patients #1 and 2) of 2 active patient records reviewed, the SN failed to report to the physician pain levels out of parameters. This failure placed patients at risk of not receiving interventions when needed to prevent complications, and a decline in the patients’ health status. FINDINGS INCLUDE: Patient #1: Review of the record revealed a POC dated 011/26/2024 to 01/24/2025 with a SOC date 05/30/2024. The POC included the diagnoses osteoporosis (bone disease that weakens the bones) and dorsalgia (pain in the back). The POC included SN visits twice a week for nine weeks. The SN was instructed to, “Notify Physician of vital sign parameters out of range: … Pain Scale: >5/10 (level of greater than 5) …” SN visit notes dated: 11/27/2024; 12/02/2024; 12/04/2024; 12/18/2024; 12/26/2024 and 01/08/2025 were completed by LVN, B and included pain assessment levels of 6. No notification to the physician of the pain levels out of parameter was documented in the SN notes. During a home visit interview with Patient #1 on 02/21/2025 at 3:15 PM, the surveyor asked about the care and services provided by the agency. The patient stated the nurse (LVN B) visited every week and checked her vital signs and blood pressure. Patient #1 stated (LVN B) asked about her pain level and to her knowledge, (LVN B) had not called the doctor to report any pain levels. Patient #2: Review of the record revealed a POC dated 11/08/2024 to 01/06/2025 with a SOC date 03/19/2023. The POC included the diagnoses: Diabetes type 2 with diabetic neuropathy (complication of diabetes that damages the nerves) and Rheumatoid arthritis (a chronic autoimmune disease that primarily affects the joints). The POC included SN visits twice a week for nine weeks. The SN was instructed to, “Notify Physician of vital sign parameters out of range: … Pain Scale: >5/10 (level of greater than 5). …” SN visit notes dated: 11/11/2024 and 12/16/2024 were completed by LVN, B and included pain assessment levels of 6. SN visit notes dated 11/13/2024; 11/18/2024; 11/20/2024; 11/25/2024; 11/27/2024; 12/02/2024; 12/04/2024; 12/09/2024; 12/11/2024; 12/18/2024; 12/26/2024 and 12/30/2025 were completed by LVN, B and included pain assessment levels of 7. No notification to the physician of the pain levels out of parameter was documented in the SN notes. During a home visit interview with Patient #2 on 02/21/2025 at 3:30 PM, the surveyor asked about the care and services provided by the agency. The patient stated the nurse (LVN B) visited every week and checked his vital signs and blood pressure. Patient #2 stated (LVN B) asked about his pain level and to his knowledge, (LVN B) had not called the doctor to report any pain levels. Patient #2 stated he received shots about every 3 months in his left knee to help with the pain. In a phone interview with LVN, B on 02/24/2025 at 10:45 AM, the surveyor asked if LVN B would be available to respond to some questions regarding the SN visits with patients. LVN B stated he could not talk or interview at this time because he was working another job. He stated he would not be able to interview until after 6 pm tonight or tomorrow night. LVN B stated the AA could answer questions on his behalf. In an interview with the AA on 02/24/2025 at 10:50 AM, the surveyor reviewed the findings and asked if there was any additional documentation to show LVN B had contacted the physician when pain levels were out of parameters for Patient #1 and #2. AA looked at the electronic health records on his computer and stated there was no communications to the physician during the certification periods reviewed. AA stated he was not a clinical person. The surveyor asked if the Administrator/DON would be available for an interview. The AA stated the Administrator/DON worked at another full time job and stated she (Administrator/DON) would pick up the call if she could. He called the Administrator/DON and placed the call on speaker. The surveyor reviewed the findings and asked the Administrator/DON why the LVN, B did not follow the plan of care and notify the physician of pain levels out of parameter for Patient’s #1 and #2. The Administrator/DON stated she did not know why he (LVN B) did not call and “it’s unfair to answer, he was the one that saw the patients.” The surveyor asked if the Administrator/DON reviewed the SN notes. She stated she had not read the SN notes this period. The surveyor asked what the risk to patients could be if an elevated pain level was not reported. The Administrator/DON stated, “if the patient has pain, of course it will affect other things, but I didn’t look at the patients, the (LVN B) saw them.” Agency Policy, revised date 03/16/2004, quoted in part, “PLAN OF CARE, TX. 6, PURPOSE: To ensure that care provided is appropriately planned in a timely manner to meet the patient’s specific needs and problems. … .” Agency Policy, dated 07/01/2012, quoted in part, “RESPONSIBILITIES OF THE ADMINISTRATOR, LD. 6, POLICY, … The Administrator will be responsible for implementing and supervising … the provision of all services to agency patients on a day-to-day basis. …””

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on observation, record review and interview the agency failed to ensure the comprehensive assessment was completed within 5 days of the end of a 60 day period for 1 (Patient #1) of 2 current patients. Failure to complete the comprehensive assessments placed all patients at risk of poor care planning, a decline in health status and poor outcomes. FINDINGS INCLUDE: In an interview with the AA on 02/18/2025 at 2:00 PM, the surveyor asked about the agency’s current active patients. The AA stated he only had 2 active patients. In an interview with the AA on 02/18/2025 at 2:45 PM, the surveyor if a recertification comprehensive assessment had been completed for Pt. #1. The AA stated there was no “recert” done yet for Pt. 1 yet, “it was due when I was out of town and I couldn’t schedule it, she (the RN) couldn’t get into the system (electronic health records system).” Patient #1: Review of the record revealed a POC for the certification period 11/26/2024 to 01/24/2025 with a SOC date 05/30/2024. The last SN visit note in the record was dated 01/15/2025 and signed by LVN, B. The SN note dated 01/15/2025 included, “… PLAN FOR NEXT VISIT, Patient education, direct patient care, and medication management. No discharge documentation was found in the record. During a home visit interview with Patient #1 on 02/21/2025 at 3:15 PM, the surveyor asked about care and services provided by the agency. Pt. 1 stated LVN B visited her twice a week. The surveyor asked when the RN last visited the patient. Pt. #1 stated, “maybe after Christmas.” The surveyor asked if the agency had discussed any plans of discharge with Pt. #1. She stated, “on no, we love (LVN B).” The recertification comprehensive assessment was due to be completed no later than 01/24/2025 the last day of the last 60 day episode. The clinical record failed to contain a recertification comprehensive assessment. In an interview with the AA on 02/24/2025 at 12:45 PM, the surveyor reviewed the findings and asked why the recertification comprehensive assessment had not been completed within the last 5 days of the last episode for Pt. 1. The AA stated, “Pt. #1’s (recertification comprehensive assessment) hasn’t been done yet. It will be late, it was assigned over the weekend and now it’s scheduled for this week.” The surveyor asked how patients care could be affected if comprehensive assessments were late. The AA stated, “I told (LVN B) to look at Pt. #1 when he goes at that time (for the weekly visit). The recert (recertification) for Pt. 2 was done.” Agency policy, revised date 11/01/2001, quoted in part, “PATIENT REASSESSMENT/RECERTIFICATION/SIGNIFICANT CHANGE IN CONDITION/POST HOSPITAL ASSESSMENT, PE.4, PURPOSE: To establish criteria for reassessment of the patient and revision of the plan of care based on this assessment. … POLICY: Agency will reassess each patient on an ongoing basis to evaluate current problems and needs as well as to adjust the care provided as needed with necessary physician orders obtained. The Recertification/Follow-Up Comprehensive Assessment which includes OASIS data set, will be updated and revised: During the last five (5) days of the episode, …” Agency policy revised date 05/01/2011, quoted in part, “TIMELINES, IM.10, … POLICY: Agency will ensure timely provision of care and services to meet the patient’s needs in compliance with all federal and state laws and regulations. PROCEDURE: … 1.6 Recertification/comprehensive reassessments will be completed no earlier than 5 days prior to end of cert (56th through the 60th day). …””

“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 observation, record review and interview the agency failed to ensure supervision of home health aide services no less frequently than every 14 days for 1 (Patient #2) of 1 patient who received hha services. This failure potentially placed patients who received hha services at risk for receiving substandard or unsafe care from hha’s when care was not verified. FINDINGS INCLUDE: Patient #2: Review of the record revealed a POC dated 11/08/2024 to 01/06/2025 with a SOC date 03/19/2023. The POC included the diagnoses: Diabetes type 2 with diabetic neuropathy and Rheumatoid arthritis. The POC included SN and hha visits twice a week for nine weeks. The SN was instructed to, “Notify Physician of vital sign parameters out of range: … Pain Scale: >5/10 (level of greater than 5). …” The hha was for “assistance with ADLS/IADLS (basic tasks an individual performs to maintain their daily life and live independently). An undated hha care plan was completed for the certification period 11/08/2024 to 01/06/2025. The care plan included the Case Manager, RN, the following assigned tasks: laundry; make the bed; change linens; tidy room; meal preparation; assist with ambulation and mobility; personal care; assist with dressing; hair care; shampoo hair; skin care; shave; deodorant; Assess skin condition; clean bathroom; clean kitchen; safety check; universal precautions and assist with exercise. Hha visit were notes dated: 11/11/2024; 11/15/2024; 11/18/2024; 11/22/2024; 11/25/2024; 11/29/2024; 12/02/2024; 12/06/2024; 12/09/2024; 12/13/2024; 12/16/2024; 12/20/2024; 12/23/2024; 12/27/2024 and 12/30/2024 and signed by the hha, D. The record did not contain any hha supervisory visits. During a home visit interview with Patient #2 on 02/21/2025 at 3:30 PM, the surveyor asked about the care and services provided by the agency. The patient stated the hha assisted him on Mondays and Fridays and has been with him a long time, she was a family member. In an interview with the AA on 02/24/2025 at 1:00 PM, the surveyor reviewed the findings and asked if supervisory visits were performed for Patient #2 who received hha services. AA stated RN C performed hha supervisory visit when she did the recertification visit for Patient #2 and showed the surveyor a supervisory visit completed by RN C for the LVN B during a recertification visit. Surveyor stated the supervisory visit provided was for the LVN (B), not the hha D. Surveyor stated the rule for hha supervisory visits was no less than every 14 days. AA stated, “the CNA (hha, D) did it (supervisory visit).” The surveyor stated a CNA was not qualified to perform a supervisory visit for a hha. The AA stated the CNA did the supervisory visits for the PHC (non-skilled assistance program). The surveyor stated the PHC program was not a medical model and it was fine for the CNA to complete the supervisory visits for the PHC program, but no the Medicare skilled care program. AA stated he did not know. Surveyor requested a copy of the agency’s policy for hha supervision. A hha policy for hha competency was presented and the surveyor stated a policy for hha supervision was requested. AA reviewed the agency policy book and stated, “I know we’ve had it, some of the policies are older, we probably need to update, I can’t find it.””