Rising Home Healthcare Inc.

“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 provide a completed written Notice of Medicare Non-Coverage (CMS form 10123) no later than two days in advance of terminating on-going care in two of two discharged records reviewed (Patient 1 and 2) in that: Patient 1 did not receive a completed written Notice of Medicare Non-Coverage no later than two days in advance of the agency terminating on-going care whose reason for discharge was a change in payor source. The agency failed to provide the CMS form titled, “Notice of Medicare Non-Coverage.” Patient 2 did not receive a completed written Notice of Medicare Non-Coverage no later than 2 days in advance of the agency terminating on-going care that included the correct QIO (Medicare beneficiaries can appeal their provider service terminations to a QIO) phone number whose reason for discharge was goals met. The agency failed to provide the CMS form titled, “Notice of Medicare Non-Coverage.” This failure could place the patients at risk of harm due to inadequate or inappropriate continuity of care in the patient’s post-discharge needs and could prevent the patient’s from exercising their right to appeal the discharge decision, if desired. Patient 1: Record review of an agency form titled, “Active and Non-Active Patients” included a discharge date of 07/31/2022. The form did not include the reason for discharge. Record review of the paper medical record included a plan of care dated 06/06/2022 to 08/06/2022 with a start of care date of 12/10/2021. The plan of care included orders for nursing visits one time a week for nine weeks. The record did not include a Notice of Medicare Non-Coverage. During an interview with the Adm/ADON and Alt Adm/DON on 12/14/2023 at 11:39 AM, the surveyor asked why Patient 1 was discharged from the agency. The Adm/ADON stated Patient 1 changed insurance from traditional Medicare to a Medicare HMO (health insurance provider that limits member coverage to medical care provided through a network of doctors and other healthcare providers who are under contract with the HMO) plan without the agency being aware, and the agency immediately discharged the patient since the HMO plan was out of network with the agency. The Adm/ADON stated the agency did not get paid for services provided since they were not in-network with the Medicare HMO plan. During an interview with the Adm/ADON and Alt Adm/DON on 12/14/2023 at 2:25 PM, the surveyor asked if an in-person discharge visit was conducted when Patient 1 was discharged on 07/31/2022. The Alt Adm/DON stated, “No.” The surveyor asked why discharge planning was not done in advance of discharging Patient 1. The Alt Adm/DON stated the agency did not let Patient 1 know in advance of discharge because the patient did not let the agency know in advance that she changed to a Medicare HMO plan. The surveyor asked why the patient did not receive a completed written Notice of Medicare Non-Coverage in advance of the agency terminating on-going care. The Alt Adm/DON stated they did not have to give discharge notices since the patient switched to an HMO. Patient 2: Record review of an agency form titled, “Active and Non-Active Patients” did not include Patient 2. During an interview with the Adm/ADON and Alt Adm/DON on 12/14/2023 at 11:39 AM, the surveyor asked when and why Patient 2 was discharged from the agency. The Alt Adm/DON stated the discharge date was 01/14/2021 due to goals met. Record review of the paper medical record included a plan of care dated 11/16/2020 to 01/14/2021 with a start of care date of 07/30/2018. The plan of care included orders for nursing visits and home health aide visits one time a week for eight weeks. The record included a two-page Notice of Medicare Non-Coverage signed and dated by Patient 2 on 01/14/2021, the same day of agency discharge. The form included the QIO phone number as (844) 430-9504 to appeal the discharge decision, if the patient chose to do so. The record included an agency form titled, “Communication Sheet” signed and dated by the Alt Adm/DON on 01/11/2021 and read in part, “…Skilled nurse communicated with patient that she will be discharged from home healthcare agency on…01/14/2021…” The record included an agency form titled, “PHYSICIAN’S TELEPHONE/VERBAL ORDER” signed and dated by Alt Adm/DON on 01/14/2021 and read in part, “…Discharge patient from home healthcare Agency, goals met effective 1/14/21…” The order was not signed by the physician. During an interview with the Adm/ADON and Alt Adm/DON on 12/14/2023 at 2:38 PM, the surveyor asked why the Notice of Medicare Non-Coverage was given and signed by the patient on the same day of agency discharge and no later than two days in advance of terminating on-going care. The Alt Adm/DON stated the Alt Adm/DON had been sick during that time and she forgot to give it to the patient before discharge. The surveyor asked why the patient was provided the wrong QIO phone number on the form instead of the accurate phone number of (888) 315-0636. The Alt Adm/DON stated the agency did not know the phone number changed. The surveyor asked if the agency provided a copy of the notice of Medicare Non-Coverage prior to her discharge. The Alt Adm/DON stated, “No.” Agency policy titled, “Criteria for Patient Admission and Discharge PE.1” with a revision date of 04/01/2011 read in part, “…C. Criteria for Patient Discharge from Agency without 5 Days Prior Notification 1. Upon the client’s request; 2. If the client’s medical needs require transfer (e.g. medical emergency); or transfer to an inpatient facility); 3. In the event of a natural disaster…4. For the protection of staff or a client after the agency has made a documented and reasonable effort to notify the client, the client’s family and physician, and appropriate state or local authorities of the agency’s concern for staff or client safety…5. According to physician orders; or 6. If the client fails to pay for services...except as prohibited by federal law…” Agency policy titled, “Patient Discharge PE.6” with a revision date of 09/01/2011 read in part, “…PURPOSE To assess each patient’s discharge planning…prior to discharge from the agency…To allow patients to challenge/appeal their provider’s decisions to discharge. POLICY…Agency will provide appropriate discharge planning and notification, per regulations…Agency will deliver the generic notice (a prescribed CMS notice) to the patient…no less than two days prior to the end of the covered period…or as soon as the provider knows coverage has ended…PROCEDURE 2.4 Agency intending to discharge a patient will perform the following…Provide written notification to the patient’s parent, family, spouse, significant other or legal representative other or legal representative…2.5 Agency will ensure delivery of the written notification no later than five…days before the date on which the patient will be discharged…B. Termination Notice…1. Agency staff will provide valid delivery notice (involves both delivery and completion) of the generic notice to the beneficiary when the end of all covered care is foreseen…1.1 No later than two…days before the proposed end of covered services…If agency fails to give valid notice, patient coverage continues for at least 2 days after notice is received…2. Telephone or e-mail contact may substitute for an in person visit to deliver notice. If e-mail is used a timely return message must be received. Both must be followed by a written generic notice…and is mailed on same day 2.1 The generic notice must be prepared and mailed in duplicate, so patient…can sign and date two copies, deep one, and return a copy to agency…” Regulation: Effective July 1, 2005, the new Medicare regulations, Benefits Improvement and Protection Act, gave beneficiaries access to the new expedited determination process when their home health agency services were ending. There were two notices required by these regulations. The first was a generic notice called a Notice of Medicare Provider Non-coverage labeled “FORM No. CMS 10123” that the provider would deliver at least two days prior to when a beneficiary’s Medicare coverage of services was ending. The telephone number for the QIO was to be included in the notice. The second was a detailed notice, called a Detailed Explanation of Provider Non-Coverage that the provider would deliver to the beneficiary and the appropriate QIO only if the beneficiary requested an expedited review by the QIO of the decision that coverage for items and/or services should end. Beginning June 8, 2019, QIO assignments or contact information will change. The State assignment for Texas, Region 6, will be Kepro; Mailing Address 5201 W Kennedy Blvd. Suite 900 Tampa, FL 33609; Phone number 888-315-0636.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on record review and interview, the agency’s Alt Adm/DON failed to update and revise the comprehensive assessment at discharge in two of two (Patient 1 and 2) discharged records reviewed. This failure resulted in the agency having incomplete assessment information regarding the patient’s condition at the time of discharge. Findings Include: Patient 1: Record review of an agency form titled, “Active and Non-Active Patients” included a discharge date of 07/31/2022. Record review of the paper medical record included a plan of care dated 06/06/2022 to 08/06/2022 with a start of care date of 12/10/2021. The record included documentation of an incomplete comprehensive assessment signed and dated by the Alt Adm/DON on 04/03/2023. The comprehensive assessment did not include a patient name. The comprehensive assessment did not include the following: Page 1: M0020: patient ID number; Marital Status; M0040 patient name and address; M0050 state of residence; M0060 zip code; pharmacy name; M0063 Medicare number; M0064 social security number; M0065 Medicaid number; M0066 birth date; emergency contact name, address, relationship to patient, emergency preparedness plan information and next doctor appointment. Page 2: patient history; primary reason for home health/problems identified during admission; living arrangements/supportive assistance and a complete pain assessment. Page 3: nutritional requirements; system review; discharge date; A1250 transportation information; M2301 emergent care and M2310 reason for emergent care, if applicable. Page 4: A2121 information regarding a reconciled medication list to subsequent provider at discharge and A2122 route of current reconciled medication list to subsequent provider. Page 5: C0100 mental status information; C0200 repetition of three words and C0300 temporal orientation. Page 5 and 6: C0400 patient recollection. Page 6: C0500 BIMS summary score; C1310 signs and symptoms of delirium; physical assessment and vital signs and a complete cardiopulmonary assessment. Page 8 and 9: D0150 mood interview. Page 9: D0160 severity score of mood interview. Page 9-10: M2102 types and sources of assistance. Page 14 and 15: J0510 pain effect on sleep. Page 15-16: K0520 nutritional approaches. Page 18 and 19: O0110 special treatments, procedures, and programs. Page 19: M1041 influenza vaccine data collection. Page 19 and 20: M1046 was influenza vaccine received. Page 20: M2401 intervention synopsis and allergies. Page 21: physician notification and if a verbal order was obtained; reason for admission; summary of care and medication status. Page 22: discharge instructions; if a MSW referral was made and date and title of person who completed the form. During an interview with the Adm/ADON and Alt Adm/DON on 12/14/2023 at 1:45 PM, the surveyor asked what patient the discharge assessment was conducted on since it did not include a patient name. The Alt Adm/DON stated Patient 1. The surveyor asked why the discharge comprehensive assessment was dated 04/03/2023 when the patient’s discharge date was 07/31/2022. The Adm/ADON and Alt Adm/DON stated the comprehensive assessment was completed late because they were confused what to do since the patient changed to a Medicare HMO plan (health insurance provider that limits member coverage to medical care provided through a network of doctors and other healthcare providers who are under contract with the HMO) without their knowledge. The surveyor reviewed the discharge assessment and asked why it was not complete and blank in many areas. The Adm/ADON stated the Alt Adm/DON only completed half of the assessment since the patient changed to a Medicare HMO and was discharged. The Alt Adm/DON stated it did not matter the assessment was incomplete since the patient changed to an HMO. The surveyor asked why it did not matter. The Alt Adm/DON stated because the agency did not get paid for the services provided because of the patient’s change in insurance. Patient 2: Record review of an agency form titled, “Active and Non-Active Patients” did not include Patient 2. During an interview with the Adm/ADON and Alt Adm/DON on 12/14/2023 at 11:39 AM, the surveyor asked when Patient 2 was discharged from the agency. The Alt Adm/DON stated 01/14/2021. Record review of the paper medical record included a plan of care dated 11/16/2020 to 01/14/2021 with a start of care date of 07/30/2018. Record review of the clinical record included documentation of an incomplete, comprehensive assessment signed and dated by Alt Adm/DON on 01/14/2021. The comprehensive assessment did not include the following: Page 1: supportive assistance/care preferences summary. Page 2: a complete pain assessment. Page 3: food/environmental allergies. Page 6: vital signs; a complete cardiopulmonary assessment and M1620 bowel incontinence frequency. Page 7: M1720 reported or observed anxiety; psychosocial/mental/cognitive status and M1800 grooming. Page 8: M1870 feeding or eating ability. Page 9: medication allergies; M2005 medication intervention; M2016 patient drug education and M2102 types and sources of assistance. Page 10: limitations, education/training and risk factors related to plan of care post-discharge. Page 13: M2401 a complete intervention synopsis and discharge status. Page 14: reason for discharge. Page 15: the section labeled, “complete this section for discharge purposes” and if a copy of the summary was sent to the doctor. During an interview with the Adm/ADON and Alt Adm/DON on 12/14/2023 at 2:35 PM, the surveyor asked why the discharge assessment was incomplete throughout. The Alt Adm/DON stated it was an oversight and omission on her part. Agency policy titled, “Patient Discharge PE.6” with a revision date of 09/01/2011 read in part, “…POLICY…Agency will complete a discharge assessment…upon discharge…PROCEDURE…2. Patient discharge…2.11 Medical record documentation for discharge includes…discharge comprehensive assessment…2.12 The discharge assessment is completed within 48 hours of knowledge of discharge…””