Florence Health Care Services & Training Center in

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record reviews and interviews the agency failed to provide a written Notice of Medicare Non-Coverage (NOMNC) notice, in advance of the Home Health Agency’s termination of on-going care for 1 (Patient 3) of 3 patients’ records reviewed. This failure potentially prevented the patient from exercising the right to dispute the termination of Medicare-covered services which placed the patient at risk of interruptions in care and services after discharge. Findings: Record review of Patient 3 revealed a “Home Health Certification and Plan of Care” for period 10/01/2024 to 11/29/2024 signed by the Adm/DON/Agency Owner on 9/27/2024. The POC contained a start of care date of 6/03/2024, a primary diagnosis of Hypertensive Chronic Kidney Disease stage 2 (mild long term kidney damage caused by high blood pressure), and a nurse visit frequency of zero visits for the first week then once a week for 8 weeks. Record review of Patient 3 revealed a 5 Day Discharge Notice signed by the Adm/DON/Agency Owner with a date of discharge notification of 11/23/2024. The notice contained a planned discharged date of 11/29/2024 with the reason for discharge as “goals met.” Record review of Patient 3 revealed an Advance Beneficiary Notice of Non-coverage (CMS form that informed the patient that Medicare was expected to deny payment for a specific item or service typically due to a lack of medical necessity. It gave the patient the choice to receive the care and assume financial responsibility if Medicare denied the claim) dated 11/23/2024 and signed by Patient 3. The ABN read in part “ The effective date coverage of your current skilled nursing services will end: 11/29/2024. Reason Medicare may not pay: Medicare will not pay when goals are met. Estimated cost $1,458.00.” The ABN form did not contain the regional Quality Improvement Organization (QIO) phone number for CA1 (CMS contracted agency which received appeals from patients regarding home health discharge decisions). Record review of Patient 3 revealed a “Discharge Assessment” dated 11/29/2024 signed by the Adm/DON/Agency Owner. The assessment contained the reason for discharge as “Goals achieved.” Further review of Patient 3’s records did not provide evidence that a NOMNC (CMS form used to notify beneficiaries when their Medicare-covered services for home health are ending and how to appeal the termination of services) notice was provided to the patient prior to discharge. An interview was conducted with the Adm/DON/Agency Owner on 5/22/2026 at 11:52am. When asked about the missing NOMNC notice for Patient 3. The Adm/DON/Agency Owner stated that the agency provided the patient with the “5-day” discharge notice, and the “2-day ABN” notice 5 days (11/23/2024) prior to discharge. The surveyor requested the agency’s discharge policy dated prior to 11/01/2024 from the Adm/DON/Agency Owner on 05/22/2026 at 3:16pm. The Adm/DON/Agency Owner informed the surveyor on 5/22/2026 at 4:47pm that the representative from the policy consulting firm contracted by the Agency did not have access to the Agency’s older policies due to the Agency “freezing (pause or put on hold)” their account with the consulting firm due to the low patient census and the cost of the consulting firm. The Adm/DON/Agency Owner stated that she would email the surveyor the discharge policy she had saved on her computer prior to putting the account on hold. The surveyor received the Agency’s policy “ Patient/Client Transfer, Discharge, and Agency Dissolution” revision 01/01/2025 via email from the Adm/DON/Agency Owner on 5/22/2026 at 4:59pm. An interview was conducted with the Adm/DON/Agency Owner on 5/22/2026 at 5:10pm. When asked about the agency’s policy on patient notification prior to a planned discharge. The Adm/DON/Agency Owner stated that a 5-day discharge notice and 2-day ABN notice was provided to the patients 5 days before discharge. The surveyor shared the findings of the missing NOMNC notice for Patient 3. When asked why the NOMNC notice was not provided to the patient. The Adm/DON/Agency Owner did not directly answer the question and stated, “ I gave the ABN form it has the Medicare number they (the patients) can call that number to dispute the discharge.” When asked about the different contact phone numbers on the two forms (ABN form contained the phone number for Medicare and the NOMNC contained the QIO contact phone number for CA1). The Adm/DON stated, “Medicare would have given the patient the correct phone number if they called.” The surveyor had the Adm/DON/Agency Owner review the agency’s discharge policy. When asked why the agency’s discharge policy was not followed. The Adm/DON/Agency Owner stated, “It (The ABN notice provided to the patient instead of the NOMNC notice) was an oversight. I gave the wrong form.” When asked about the potential patient’s outcome for the failure to provide a NOMNC notice prior to discharge. The Adm/DON stated, “The patient won’t be able to call the right place (CA1 the regional QIO)” to dispute the discharge. Review of the Agency’s policy “ Patient/Client Transfer, Discharge, and Agency Dissolution” revision 01/01/2025 read in part “ Procedure. Discharge. The Agency will provide notice to eligible patients/clients of the right to expedited determinations using the Notice of Medicare Non-Coverage (an OMB-approved Medicare form) when the period of covered care ends… The Agency will provide the Advance Beneficiary Notice (ABN) according to the procedures in the Billing Process/Advance Beneficiary Notice/False Claims policy…””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure the individualized plan of care included a description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors for 3 (Patients 1, 2, and 3) of 3 patients’ records reviewed. The failure to include the patients’ risks for emergency department visits and hospital re-admissions in the individualized plan of care can potentially lead to inadequate patient education, worsening symptoms, and preventable hospital re-admissions. Findings: Record review of Patient 1 revealed a “Recertification reassessment” dated 4/22/2026 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented an ulcer (open wound or sore) to patient’s right lower leg measuring 6.8cm (length) by 4.2cm (width) by 0.2 cm (depth) and an ulcer to left ankle measuring 1.0cm (length) by 0.8cm (width) by 0.1cm (depth). The Adm/DON/Agency Owner documented that the patient received nursing visits twice a week for wound care and that the patient’s ulcers “initially developed in 2015…She (Patient 1) has been in compression wraps with both legs for…many years since 2016. She (Patient 1) has been on and off antibiotics for her wounds with some improvement.” The reassessment contained a risk for hospitalization section with the question “Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply)” and the option to select “1. History of falls (2 or more falls or any fall with an injury in the past 12 months), 2. Unintentional weight loss of a total of 10 pounds or more in the past 12 months, 3. Multiple hospitalizations (2 or more) in the past 6 months, 4. Multiple emergency department visits (2 or more) in the past 6 months, 5. Decline in mental, emotional, or behavioral status in the past 3 months, 6. Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months, 7. Currently taking 5 or more medications, 8. Currently reports exhaustion, 9. Other risk(s) not listed in 1 – 8, and 10. None of the above.” The Adm/DON/Agency Owner check marked box 9. The sections of the reassessment labeled “Intervention to prevent Hospitalization” and “Goals to prevent Hospitalization” were not completed. Record review of Patient 1 revealed a “Home Health Certification and Plan of Care” for period 04/24/2026 to 06/22/2026 signed by the Adm/DON/Agency Owner on 4/22/2026. The POC contained a start of care date of 3/05/2024, a primary diagnosis of “ Chronic Venous Hypertension (condition where abnormally high blood pressure builds up in the leg veins)” with ulcers of the right and left lower legs, and a nurse visit frequency of one visit for the first week, then twice a week for 8 weeks. Further review of the POC did not contain the patient’s risks for emergency department visits and hospital re-admission. Record review of discharged Patient 2 revealed a Start of Care assessment dated 11/02/2023 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented “ Patient was taken to the ER on 10/13/2023 only 2 days after she was discharged from the hospital on 10/11/2023…She (Patient 2) was admitted to the ICU for septic shock (a life-threatening condition that occurs when the body overreacts to an infection causing a dangerous drop in blood pressure that can cause widespread organ failure).” The assessment contained a risk for hospitalization section with the question “Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply)” and the option to select “1. History of falls (2 or more falls or any fall with an injury in the past 12 months), 2. Unintentional weight loss of a total of 10 pounds or more in the past 12 months, 3. Multiple hospitalizations (2 or more) in the past 6 months, 4. Multiple emergency department visits (2 or more) in the past 6 months, 5. Decline in mental, emotional, or behavioral status in the past 3 months, 6. Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months, 7. Currently taking 5 or more medications, 8. Currently reports exhaustion, 9. Other risk(s) not listed in 1 – 8, and 10. None of the above.” The Adm/DON/Agency Owner check marked boxes 3, 5, 7, and 9. The sections of the assessment labeled “Intervention to prevent Hospitalization” and “Goals to prevent Hospitalization” were not completed. Record review of discharged Patient 2 revealed a “Home Health Certification and Plan of Care” for period 11/02/2023 to 12/31/2023 signed by the Adm/DON/Agency Owner. The POC contained a start of care date of 11/02/2023, a primary diagnosis of “Chronic Passive Congestion of the Liver (condition where blood backs up and pools in the liver because the heart cannot pump the blood out effectively),” and a nurse visit frequency of once a week for 9 weeks and two as needed visits for tracheostomy (a small surgical hole in front of the neck where a breathing tube is placed directly into the windpipe allowing the person to breathe without using their nose or mouth) care. Further review of the POC did not contain the patient’s risks for emergency department visits and hospital re-admission. Record review of discharged Patient 2 revealed a death discharged date of 11/18/2023. Record review of Patient 3 revealed a “Recertification reassessment” dated 9/27/2024 signed by the Adm/DON/Agency Owner. The Adm/DON/Agency Owner documented “Patient was seen in ER on 8/21/2024 for abdominal pain. He was found to have a small bowel (intestines or “gut”) obstruction (blockage) and admitted (to the hospital) on 8/22/2024 for further evaluation and treatment…Previous (hospital) admission…6/18/2024 to 6/22/2024 due to rectal (opening where solid waste leaves the body) bleeding.” The reassessment contained a risk for hospitalization section with the question “Which of the following signs or symptoms characterize this patient as at risk for hospitalization? (Mark all that apply)” and the option to select “1. History of falls (2 or more falls or any fall with an injury in the past 12 months), 2. Unintentional weight loss of a total of 10 pounds or more in the past 12 months, 3. Multiple hospitalizations (2 or more) in the past 6 months, 4. Multiple emergency department visits (2 or more) in the past 6 months, 5. Decline in mental, emotional, or behavioral status in the past 3 months, 6. Reported or observed history of difficulty complying with any medical instructions (for example, medications, diet, exercise) in the past 3 months, 7. Currently taking 5 or more medications, 8. Currently reports exhaustion, 9. Other risk(s) not listed in 1 – 8, and 10. None of the above.” The Adm/DON/Agency Owner check marked boxes 3 and 7. The sections of the reassessment labeled “Intervention to prevent Hospitalization” and “Goals to prevent Hospitalization” were not completed. Record review of Patient 3 revealed a “Home Health Certification and Plan of Care” for period 10/01/2024 to 11/29/2024 signed by the Adm/DON/Agency Owner on 9/27/2024. The POC contained a start of care date of 6/03/2024, a primary diagnosis of Hypertensive Chronic Kidney Disease stage 2 (mild long term kidney damage caused by high blood pressure), and a nurse visit frequency of zero visits for the first week then once a week for 8 weeks. Further review of the POC did not contain the patient’s risks for emergency department visits and hospital re-admission. Record review of discharged Patient 3 revealed a discharged date of 11/29/2024 for goals met. The surveyor requested the agency’s Plan of Care policy dated prior to 11/02/2023 from the Adm/DON/Agency Owner on 05/22/2026 at 3:16pm. The Adm/DON/Agency Owner informed the surveyor on 5/22/2026 at 4:47pm that the representative from the policy consulting firm contracted by the Agency did not have access to the Agency’s older policies due to the Agency “freezing (pause or put on hold)” their account with the consulting firm due to the low patient census and the cost of the consulting firm. The Adm/DON/Agency Owner stated that she would email the surveyor the discharge policy she had saved on her computer prior to putting the account on hold. The surveyor received the Agency’s policy “Plan of Care” revision 05/02/2024 via email from the Adm/DON/Agency Owner on 5/22/2026 at 4:59pm. An interview was conducted with the Adm/DON/Agency Owner on 5/22/2026 at 5:10pm. When asked about the agency’s policy on the elements included on the plan of care the Adm/DON/Agency Owner stated “Diagnosis, medications, allergies, date of birth, nursing interventions, diet, the doctor’s information, goals, (patient’s) problems, orders, and visit frequency.” The surveyor shared the finding on the missing risks for hospital readmissions and Emergency Department visits on the POCs for Patients 1, 2, and 3. When asked about the missing risks for hospitalization/ER visits on the patients’ POCs and the agency’s process of adding the risks to the POCs. The Adm/DON/Agency Owner stated that information from the patient’s assessment was selected by the RN and added to the plan of care. The Adm/DON/Agency Owner stated “Whatever I needed on the plan of care, I selected it (from the assessment) and added it to the plan of care. The Plan of Care is supposed to be individualized. If they (the patients) are not at risk of going to the ER or hospital, I don’t add it (risks for hospitalizations/ER visits). I didn’t select it (the risks for hospitalizations/ER visits from the assessments) because the patients (Patients 1, 2, and 3) did not need it (risks for hospitalization/ER visits on the POC).” The surveyor had the Adm/DON/Agency Owner review the agency’s POC policy. When asked why the agency’s POC policy was not followed. The Adm/DON did not directly answer the question and stated, “I am following my (the agency’s) policy. I am not going to add it (hospitalization/ER risks) if it’s not applicable.” The Adm/DON/Agency Owner refused to provide any additional information on why the agency’s POC policy on adding the patients’ risks for hospital readmissions/ER visits was not followed or the potential patients’ outcomes for not following the agency’s policy. Review of the Agency’s policy “Plan of Care” revision 05/02/2024 read in part “The Agency will use data/information gathered during patient/client assessments in the care planning process which involves the identification of patient/client goals, actions or interventions that will resolve or alleviate the patient’s/client’s problems and/or needs…Procedure. The individualized Plan of Care must include the following: A description of the patient’s/client’s risk for emergency department visits and hospital readmission, and all necessary interventions to address the underlying risk factors.””