Alliance Homehealth Care

“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 review and interview, the agency failed to ensure the patient’s right to receive the NOMNC written notice at least two days in advance of terminating on-going care in 3 (Patient #8, #9, and #10) of 3 discharged records reviewed whose reason for discharge was “goals met.” The failure of the agency to protect the rights of the patient by informing in advance of their right to appeal the discontinuation of home health services prevented the identified patient from exercising their right to appeal the discharge decision, if they chose to appeal. Findings include: On 10/28/24 at 12:25 pm the Administrator/Supervising Nurse/RN provided the surveyor with a discharge roster. The discharge roster indicated that Patient #8, #9, and #10 were discharged with “goals met.” An interview was conducted on 10/31/24 at 9:45 am with the Administrator/Supervising Nurse/RN. The surveyor requested discharge charts for Patient #8, #9, and #10. The Administrator/Supervising Nurse/RN stated, “I might as well tell you, I have the 5 day discharge, but I do not have the Notice of Medicare Non-Coverage. Me and RN A forgot about giving the NOMNC notice.” The surveyor asked the Administrator/Supervising Nurse/RN who was responsible for providing the NOMNC. The Administrator/Supervising Nurse/RN said, “For those 3 patients, it was RN A. The surveyor asked the Administrator/Supervising Nurse/RN how not providing the NOMNC could affect the patients. The Administrator/Supervising Nurse/RN said, “They would not know they could appeal the discharge.” Patient 8: Record review of the contained a POC dated 7/15/24-9/12/24 with a SOC date of 1/17/24. The record contained a discharge OASIS assessment dated 9/12/24 and signed by RN A. The record failed to contain a NOMNC. Patient 9: Record review of the contained a POC dated 3/31/24-5/29/24 with a SOC date of 8/4/24. The record contained a discharge OASIS assessment dated 5/29/24 and signed by RN A. The record failed to contain a NOMNC. Patient 10: Record review of the contained a POC dated 6/26/24-8/24/24 with a SOC date of 3/4/23. The record contained a discharge OASIS assessment dated 8/20/24 and signed by RN A. The record failed to contain a NOMNC. An interview was conducted on 11/1/24 at 10:21 am with RN A. The Surveyor reviewed the discharge chart findings in that Patient #8, #9, and #10 charts failed to include the NOMNC with RN A. RN A said, “I give the 5 day discharge notice, I forgot about that notice (NOMNC)” The surveyor asked RN A who was responsible for providing the NOMNC. RN A said, “Me.” The surveyor asked RN A how not providing the NOMNC could affect the patients. RN A said, “They couldn’t appeal the discharge. Agency Policy: PE.6 Patient Discharge/Discharge Planning revised 7/1/21 read in part:… Purpose…To allow patient to appeal the Agency’s decisions to discharge…Policy…J. Agency will deliver the generic CMS notice NOMNC (Notice of Medicare Non Coverage) to the patient (or authorized representative), no less than two (2) days prior to the day of anticipated discharge, or as soon as the Agency determines coverage will end.”… According to OMG Form Instructions 10123-NOMNC: The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Note: The two-day advance requirement is not a 48 hour requirement. This notice fulfills the requirement at 42 CFR 405.1200(b)(1) and (2) and 42 CFR 422.624(b)(1) and (2). Additional guidance for Original Medicare and Medicare Advantage can be found, respectively, at Chapter 4, Section 260 of the Medicare Claims Processing Manual and Chapter 13, Sections 90.2-90.9 of the Medicare Managed Care Manual.”

“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 review and interview, the agency failed to ensure the plan of care included patient specific interventions. In 2 (Patient 2 and 3) of 3 records reviewed where the Patients had a diagnosis of heart failure, the plan of care failed to include specific interventions for the skilled nurse to assess for fluid retention with abnormal parameters to report to the physician. This failure placed the Patients at risk of not receiving adequate care, exacerbation of heart failure and possible hospitalization. Findings include: Patient 2: The record included a plan of care for episode 7/14/24 through 9/11/24 with a start of care date of 11/17/23. The plan of care included a diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure [hypertension] damages the heart and causes it to weaken and fail) and chronic systolic (congestive) heart failure (a type of heart failure that occurs when the left ventricle of the heart is weak and enlarged, making it unable to pump enough oxygenated blood throughout the body.) The plan of care was signed and dated by Administrator/Supervising Nurse/RN on 7/11/24. The plan of care did not include appropriate interventions for the skilled nurse to assess for fluid retention with abnormal parameters to report to the physician.[RG(1] Patient 3: The record included a plan of care for episode 8/26/24 through 10/24/24 with a start of care date of 3/5/23. The plan of care included a diagnosis of chronic systolic (congestive) heart failure chronic systolic (congestive) heart failure (a type of heart failure that occurs when the left ventricle of the heart is weak and enlarged, making it unable to pump enough oxygenated blood throughout the body.) The plan of care was signed and dated by RN A on 8/21/24. The plan of care did not include appropriate interventions for the skilled nurse to assess for fluid retention with abnormal parameters to report to the physician. An interview was conducted on 10/29/24 at 12:15 pm with the Administrator/Supervising Nurse/RN. The surveyor reviewed Client #2’s and 3’s plan of care with the diagnosis of heart failure with no interventions to assess for fluid retention and parameters for reporting to the physician. The Administrator/Supervising Nurse/RN said, “I must have missed that, I’m usually very careful about that.” The surveyor asked the Administrator/Supervising Nurse/RN who was responsible for ensuring the interventions and parameters for heart failure were included in the plan of care. The Administrator/Supervising Nurse/RN said, ‘I am.” The surveyor asked the Administrator/Supervising Nurse/RN how the plan[RG(2] of care not including the interventions to monitor for heart failure/fluid retention could affect the patient. The Administrator/Supervising Nurse/RN said, “The patient could end up in the hospital with and exacerbation of heart failure.” An interview was conducted on 10/30/24 at 8:30 am via phone with RN A. The Surveyor reviewed Patient #2’s and 3’s plan of care in that both had a diagnosis of heart failure, but their plans of care did not include interventions to monitor for fluid retention or parameters for reporting to the physician. RN A said, “I missed making sure the interventions and parameters were included in the plan of care.” The surveyor asked RN A who was responsible for the plan of care to include all interventions necessary to care for the patients. RN A said, “I am.” The surveyor asked how the plan of care not including interventions to monitor for fluid retention with parameters for reporting to the physician could affect the patients. RN A said, “The patient could go back into the hospital.” According to, https://heart-failure.net/symptoms/swelling, worsening signs and symptoms of heart failure that should be reported to the physician include a weight gain of 2-3 pounds in a single day or 5+ pound in one week, increased swelling in the feet or ankles or swelling or pain in the abdomen. Agency policy: TX.6 Plan of Care last revised 12/29/22 read in part:…” Purpose To develop an individualized plan of care which specifies the care and services necessary to meet the patient specific needs and according to state and federal regulations… Policy A. Each patient will receive an individualized written plan of care…Procedure…C. The individualized Plan of Care will specify the care and services necessary to meet the patient specific needs…The POC will contain he following elements:…14. Patient-specific interventions and education…””