Cordial Care Home Health Services Inc.

“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 record review and interview the agency failed to transmit OASIS data for each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the beneficiary for 153 of 153 OASIS assessments submitted from 08/02/2023 to 08/21/2024. Failure of the agency to transmit OASIS data within the required time frame prevented the agency’s patient data from being made available to CMS for analysis to evaluate the agency performance levels in the provision of patient care. The surveyor reviewed the OASIS Error Detail Report for the agency in the IQIES portal on 08/22/2024, as part of the preparation for the survey. The report documented 153 late assessments transmitted from 08/02/2023 to 08/21/2024 were submitted more than 30 days after the M0090 (the date of completion of the assessment.) During the entrance conference on 08/22/24 at 11:45 AM, the surveyor noted the late submissions found during survey preparation and asked for OASIS final validation reports for the last two years. The surveyor reviewed the OASIS Agency Final Validation reports provided by the agency which documented the late OASIS submissions with the comment “Record Submitted Late: The submission date is [HC(1] more than 30 days after M0090 on this new record.” An interview was conducted with interview with Administrator on 8/27/24 at 11:33 AM. The surveyor reviewed the late transmissions of OASIS assessments with the Administrator. The surveyor asked who was responsible for transmitting the assessments. The Administrator stated she did the transmissions, and transmitted as soon as an OASIS was completed. The Administrator stated the nurses’ delays in completing the OASIS caused the delays. Agency policy titled: “IM.10 Timeliness revised date: 112910” read in part: 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 - A. All Agency staff, and physician/physician office staff as appropriate, will be oriented to the following parameters: 1. Evaluation visit for admission to Agency is within 48 hours of referral, discharge from hospital or on physician specific start of care order date. 2. Admission paperwork is completed within 2 days of admission to Agency. 3.Plan of care is established within 3-5 days of admission to Agency. 4. A Registered Nurse will complete the Initial Comprehensive Assessment no later than five (5) calendar days after the start of care (SOC) date for all patients in a licensed and certified agency… Encoding and submission of OASIS data to the state at least monthly and prior to billing…. “”

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on observation, record review and interview for 3 (Patient 1,2, and 3) of 3 patients the surveyor made home visits with, the agency failed to ensure the patients’ right to be advised of the contact information for the following Federally - funded and state-funded entities: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. The failure placed patients at risk of missing resources in the area that might assist them in maintaining their health, finding appropriate housing, and to be able to appeal discharge decisions by the agency. During the entrance conference on 08/22/2024 at 11:45 AM the surveyor requested the agency sample admission file. The surveyor reviewed the sample file provided on 08/27/2024 and found a blue pocket folder with the agency’s name, address, phone on the cover. Review of the documents and policies in the folder revealed no contact information for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and the Quality Improvement Organization. During a home visit with Patient 1 and his family member on 08/23/2024 at 10 AM, the surveyor reviewed the home folder provided by the agency. The folder contained no contact information for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and the Quality Improvement Organization. The surveyor asked if any of the documents or policies provided by the agency in the home folder had been removed. Patient 1 and his family member stated they had not removed anything. During a home visit with Patient 2 and his family member on 08/23/2024 at 11:30 AM, the surveyor reviewed the home folder provided by the agency. The folder contained no contact information for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and the Quality Improvement Organization. The surveyor asked if any of the documents or policies provided by the agency in the home folder had been removed. Patient 2 and his family member stated they had not removed anything, and the folder was always kept in the box shown to the surveyor with Patient 2’s wound care supplies. During a home visit with Patient 3 on 08/23/2024 at 1 PM, the surveyor reviewed the home folder provided by the agency. The folder contained no information no contact information for the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and the Quality Improvement Organization. The surveyor asked if any of the documents or policies provided by the agency in the home folder had been removed. Patient 3 stated they had not removed anything. An interview was conducted with the Administrator on 08/27/2024 at 11:33 AM the surveyor reviewed the sample admission packet and the findings from the home visits and asked about the resource list. The Administrator stated they did not know why everything wasn’t in the folder. The surveyor asked for a copy of the resource list. The surveyor asked who was responsible for ensuring all the required documents were in the patient’s admission folders. The Administrator stated that it was her responsibility, and she had delegated that recently and the Administrator would do them again. Review of agency policy and procedures found no policy and procedure directing the agency staff in providing the names, addresses, and telephone numbers of the following federally funded and state funded entities that serve the area where the patient/client resides: 1. Agency on Aging 2. Center for Independent Living 3. Protection and Advocacy Agency 4. Aging and Disability Resource Center 5. Quality Improvement Organization…””

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on record review and interview the comprehensive assessment for 2 (Patient 4 and 5) of 2 patient records reviewed who had kidney failure failed to contain a completed assessment of the patient’s current health status including the renal dialysis access device (an Arteriovenous shunt – a surgical joining of artery and vein used for hemodialysis access).(Hemodialysis is the external process of removing excess water and toxins from the blood of those whose kidneys can no longer perform these functions.) Patients were at risk of potential harm and unsafe care by the lack of complete assessments from which the patient’s Plans of Care were generated. Review of Patient 4’s plan of care for the certification 07/08/24 to 09/05/24 revealed diagnoses of Hypertension without Heart Disease (high blood pressure), End Stage Renal Disease (complete kidney failure), and Dependence on renal dialysis. Review of the comprehensive assessment dated 07/03/24 by RN A failed to find a completed assessment of the Patient’s dialysis access site. The assessment contained a wound care sheet which documented “dialysis access” and was marked “yes” to the patient was on dialysis. The assessment documented the patient had an AV graft / Fistula site on the Left Upper Arm. Review of the entire assessment failed to find an assessment of the status of the AV shunt. There was no description of the skin and whether the AV shunt had signs of bleeding or infections, and no documentation of a Thrill and Bruit (indicators of blood flow through the shunt.) The record review revealed visit notes by LVN A dated 07/11/2024, 07/18/2024, 07/25/2024, 08/01/2024, 08/15/2024, and 08/22/2024 which also revealed no complete assessment of the patient’s dialysis access site. Blood pressures were documented on each of these visits. Review of Patient 4’s plan of care revealed no orders for the assessment of the dialysis access site for blood flow, bleeding, and signs of infection. The Plan of care failed to include the safety requirement to avoid taking the blood pressure on the unaffected limb. The results of the record reviews and home visit findings were shared with the Administrator during the exit conference on 11/28/2023 at 3:00 PM. The Administrator had no other information to provide at the exit conference regarding the findings. Review of Patient 5’s plan of care for the certification 02/21/2024 to 04/20/2024 revealed diagnoses of Hypertension and End Stage Renal Disease, Diabetes Mellitus 2 (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and Mild Cognitive Impairment (when a person has problems with their memory.) Review of the start of care comprehensive assessment dated 02/21/24 by the Supervising Nurse failed to find a completed assessment of the Patient’s dialysis access site. The assessment contained a wound care sheet which documented left upper arm AV shunt” and was marked “yes” to the patient was on dialysis. The assessment documented the patient was on Eliquis (a blood thinner) for Deep Vein Thrombosis (blood clot in a deep vein, usually in the legs). Review of the entire assessment failed to find an assessment of the status of the AV shunt. There was no description of whether the AV shunt had signs of bleeding or infections, and no documentation of a Thrill and Brui (indicators of blood flow through the shunt.) The discharge comprehensive assessment dated 06/19/2024 by the Supervising Nurse also failed to document a completed assessment of the AV shunt. The record review revealed visit notes by LVN B dated 04/23/2024, 04/29/2024, 05/06/2024, 05/15/2024, 06/03/2024, and 06/10/2024 which also revealed no complete assessment of the patient’s dialysis access site. Blood pressures were documented on each of these visits. Review of Patient 5’s plan of care revealed no orders for the assessment of the dialysis access site for blood flow, bleeding and signs of infection. The Plan of care failed to include the safety requirement to avoid taking the blood pressure on the unaffected limb. An interview was conducted with RN A on 08/27/2024 at 1:30 PM. The surveyor asked about Patient 4’s assessment and plan of care. RN A stated he did the assessment on July 3. The surveyor asked the nurse what the nurse looking for when assessing a patient with a dialysis shunt. RN A stated: “I am looking for the location of the AV shunt, where it is located, if the patient has an infection on that on that AV shunt, and if the dialysis access is working correctly. I will put my hand on the shunt and feel the flow. The surveyor asked why that information was not found on the assessment. RN A stated they just learned something from the surveyor that this should be on the assessment. The surveyor asked about orders for assessment and safety related to the dialysis shunt. RN A stated it was not on the plan of care because he did not put it in the assessment. The surveyor asked if RN A discussed this assessment need with the LVN who saw the patient after the RN assessment. RN A stated he did not speak with the LVN, and he only saw Patient 4 the one time. The results of the record reviews shared with the Administrator and Alternate Supervising Nurse on 08/27/24 at 12:20 PM. The surveyor asked what the Alternate Supervising Nurse expected to see documented in the assessments and plan of care for clients with end stage renal disease. The Alternate supervising nurse stated the location and description of the dialysis access whether it was a central line or an AV shunt. If it was free of signs of infection or bleeding, if it had blood flow through it. The surveyor reviewed the findings from the clinical record reviews and asked about the lack of assessment of clients 4 and 5’s AV shunts. The ADON reviewed the assessments and plans of care for dialysis patients, and stated she did not find assessments and orders for AV shunts. The ADON stated she sees the area where the staff should have put the assessment information and intervention information. The ADON stated the staff has to put the information into the assessment and it flows to the orders in the Plan of Care. The surveyor asked who was responsible for review of the assessments and plans of care. The Administrator stated it was the Supervising Nurse who reviewed the assessments and plans of care. The surveyor asked to speak with the Supervising Nurse. The Administrator stated the Alternate Supervising Nurse was the one available to answer the questions on this day. Agency policy and procedures titled: Patient / Client Assessment Guidelines PE.2 revised “101205” read in part: Purpose To provide accurate and consistent patient/client assessments. Policy I. The Agency will use and adhere to a defined comprehensive assessment to identify the patient’s/client’s needs for home care, and to meet the patient’s/client’s medical, nursing, rehabilitative, social, and discharge planning needs. The Comprehensive Assessment and OASIS data collection will be completed by primary provider – A Registered Nurse… The assessment data/information will be gathered and documented on the appropriate discipline’s assessment form(s). The comprehensive assessment will be performed by the primary provider and will accurately reflect the patient’s/client’s status at the time of assessment…” Review of the Lippicott Procedures – Hemodialysis access care, home care dated 5/5/21 revealed in part “…Inspect the AV access extremity and compare it with the other extremity, noting any obvious differences, assess the AV access extremity for swelling, redness, warmth, drainage from prior needle sites, ecchymosis (black and blue areas), …Auscultate for the presence of a bruit (whooshing sound (blood flow) and palpate (touch) the AV access for a continuous sensation, known as a “thrill” (pulse) (patency)…Document all assessments including…as well as your assessment of the AV access extremity and AV access site…””

“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 for 2 (Patient 4 and 5) of 2 patients who were receiving hemodialysis (the external process of removing excess water and toxins from the blood of those whose kidneys can no longer perform these functions) while receiving agency services included the following: patient specific interventions and safety measures to protect against injury and all necessary interventions to address the patients underlying risk factors. The Plans of care failed to include orders to assess the hemodialysis access site (a surgical joining of artery and vein used for hemodialysis access), and orders to direct the safety practice of no blood pressure checks on limbs with surgical dialysis access locations. This failure meant the patients were subjected to potential harm and poor-quality care. Review of Patient 4’s plan of care from 07/08/24 to 09/05/24 revealed diagnoses of Hypertension without Heart Disease (high blood pressure), End Stage Renal Disease (complete kidney failure), and Dependence on renal dialysis. There was no documented evidence on the POC that the SN was to assess Patient 4#’s dialysis access for bruit and thrill, and skin condition. Review of the comprehensive assessment dated 07/03/24 by RN A failed to find a completed assessment of the client’s dialysis access site. The assessment contained a wound care sheet which documented “dialysis access” and was marked “yes” to the patient was on dialysis. The assessment documented the client had an AV graft / Fistula site (surgical cite from the joining of an artery and a vein used for hemodialysis) on the Left Upper Arm. Review of the entire assessment failed to find an assessment of the status of the AV shunt. There was no description of whether the AV shunt had signs of bleeding or infections, and no documentation of a Thrill and Bruit[ (indicators of blood flow through the shunt.) The record review revealed visit notes by LVN A dated 07/11/2024, 07/18/2024, 07/25/2024, 08/01/2024, 08/15/2024, and 08/22/2024 which also revealed no complete assessment of the client’s dialysis access site. Blood pressures were documented on each of these visits. Review of Patient 5’s plan of care from 02/21/2024 to 04/20/2024 revealed diagnoses of Hypertension and End Stage Renal Disease, Diabetes Mellitus 2 (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and Mild Cognitive Impairment (when a person has problems with their memory.) Review of Patient 5’s plan of care revealed no orders for the assessment of the dialysis access site for blood flow, bleeding and signs of infection. The Plan of care failed to include the safety requirement to void taking the blood pressure on the unaffected limb. Review of the start of care comprehensive assessment dated 02/21/24 by the DON failed to find a completed assessment of the client’s dialysis access site. The assessment contained a wound care sheet which documented left upper arm AV shunt” and was marked “yes” to the indicate the client was on dialysis. The assessment documented the client was on Eliquis (a blood thinner) for Deep Vein Thrombosis (blood clot in a deep vein, usually in the legs). Review of the entire assessment failed to find an assessment of the status of the AV shunt. There was no description of whether the AV shunt had signs of bleeding or infections, and no documentation of a Thrill and Bruit (indicators of blood flow through the shunt.) The discharge comprehensive assessment dated 06/19/2024 by the DON also failed to document a completed assessment of the AV shunt. The record review revealed visit notes by LVN B dated 04/23/2024, 04/29/2024, 05/06/2024, 05/15/2024, 06/03/2024, and 06/10/2024 which also revealed no complete assessment of the DON’s dialysis access site. Blood pressures were documented on each of these visits. An interview was conducted with RN A on 08/27/2024 at 1:30 PM. The surveyor asked about Patient 4’s assessment and plan of care. RN A stated he did the assessment on July 3,2024. The surveyor asked the nurse what the nurse looking for when assessing a patient with a dialysis shunt. RN A stated: “I am looking for the location of the AV shunt, where it is located, if the patient has an infection on that on that AV shunt, and if the dialysis access is working correctly. I will put my hand on the shunt and feel the flow. The surveyor asked why that information was not found on the assessment. RN A stated they just learned something from the surveyor that this should be on the assessment. The surveyor asked about orders for assessment and safety related to the dialysis shunt. RN A stated it was not on the plan of care because he did not put it in the assessment. The surveyor asked if RN A discussed this assessment need with the LVN who saw the patient after the RN assessment. RN A stated he did not speak with the LVN, and he only saw Patient 4 the one time. The results of the record reviews and were shared with the Administrator and ADON on 08/27/24 at 12:20 PM. The surveyor asked what the ADON expected to see documented in the assessments and plan of care for clients with end stage renal disease. The ADON stated the location and description of the dialysis access whether it was a central line or an AV shunt. If it was free of signs of infection or bleeding, if it had blood flow through it. The surveyor reviewed the findings from the clinical record reviews and asked about the lack of assessment of clients 4 and 5’s AV shunts. The ADON reviewed the assessments and plans of care for dialysis patients, and stated she did not find assessments and orders for AV shunts. The ADON stated she sees the area where the staff should have put the assessment information and intervention information. The ADON stated “the staff has to put the information into the assessment, and it flows to the orders” in the Plan of Care. The surveyor asked who was responsible for review of the assessments and plans of care. The Administrator stated it was the DON who reviewed the assessments and plans of care. The surveyor asked to speak with the DON. The Administrator stated the ADON was the one available to answer the questions on this day. Agency policy and procedures titled: Patient / Client Assessment Guidelines PE.2 revised “101205” read in part: Purpose To provide accurate and consistent patient/client assessments. Policy I. The Agency will use and adhere to a defined comprehensive assessment to identify the patient’s/client’s needs for home care, and to meet the patient’s/client’s medical, nursing, rehabilitative, social, and discharge planning needs. The Comprehensive Assessment and OASIS data collection will be completed by primary provider – A Registered Nurse… The assessment data/information will be gathered and documented on the appropriate discipline’s assessment form(s). The comprehensive assessment will be performed by the primary provider and will accurately reflect the patient’s/client’s status at the time of assessment…” Agency policy titled: Care Planning Process TX.7 revised “040109 read in part: “Purpose - To ensure that care provided is appropriately planned in a timely manner to meet the patient’s specific needs and problems… Policy – Agency will utilize data/information gathered during patient assessments in the care planning process which involves the identification of patient goas, actions or interventions that will resolve or alleviate the patient’s problems and / or needs…” Review of the Lippincott Procedures – Hemodialysis access care, home care dated 5/5/21 revealed in part “…Inspect the AV access extremity and compare it with the other extremity, noting any obvious differences, assess the AV access extremity for swelling, redness, warmth, drainage from prior needle sites, ecchymosis (black and blue areas), …Auscultate for the presence of a bruit (whooshing sound (blood flow) and palpate (touch) the AV access for a continuous sensation, known as a “thrill” (pulse) (patency)…Document all assessments including…as well as your assessment of the AV access extremity and AV access site…””

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, record review and interview for 3 (Patient 1, 2, and 3) of 3 patients the surveyor made home visits with the agency failed to provide a visit schedule including frequency of visits by the agency’s staff and contractors based on the patient’s most current plan of care. The failure placed patients at risk of missing and overlapping visits. During the entrance conference on 08/22/2024 at 11:45 AM the surveyor requested the agency sample admission file. The surveyor reviewed the sample file provided on 08/27/2024 and found a blue pocket folder with the agency’s name, address, phone on the cover. Review of the documents and policies in the folder revealed no schedule form or document for staff to provide to the patients. During a home visit with Patient 1 and his family member on 08/23/2024 at 10 AM, the surveyor reviewed the home folder provided by the agency. The folder contained no schedule for services. The surveyor asked if any of the documents or policies provided by the agency in the home folder had been removed. Patient 1 and his family member stated they had not removed anything. The surveyor asked if the agency had provided a written schedule of the visits. The patient and family member stated they did not have a schedule. The patient and family member stated they had therapy services for Lymphedema treatments (swelling caused by blockage in the lymphatic system treated with exercise, wrapping, massage and compression) and were waiting for notice about a lymphedema pump. The stated they did not know when the next visit was scheduled. During a home visit with Patient 2 and his family member on 08/23/2024 at 11:30 AM, the surveyor reviewed the home folder provided by the agency. The folder contained no schedule for services. The surveyor asked if any of the documents or policies provided by the agency in the home folder had been removed. Patient 2 and his family member stated they had not removed anything, and the folder was always kept in the box shown to the surveyor with Patient 2’s wound care supplies. The surveyor asked if the agency had provided a written schedule of the visits. The patient and family member stated they did not have a schedule. The patient and family member stated they had a nurse who changed the wound and therapy services for lymphedema treatments. The patient stated the nurse tells the patient the day prior to the next visit. The patient stated he had missed a few visits due to not knowing when the next visit was scheduled. During a home visit with Patient 3 on 08/23/2024 at 1 PM, the surveyor reviewed the home folder provided by the agency. The folder contained no schedule for services. The surveyor asked if any of the documents or policies provided by the agency in the home folder had been removed. Patient 3 stated they had not removed anything. The surveyor asked if the agency had provided a written schedule of the visits. The patient stated they did not have a schedule. The patient stated they had staff who wrapped their legs for swelling. The patient stated they did not know when the staff were coming next. The patient stated they had trouble remembering things. An interview was conducted with the Administrator on 08/27/2024 at 11:33 AM the surveyor reviewed the sample admission packet and the findings from the home visits and asked about the resource list. The Administrator stated they did not know why everything wasn’t in the folder. The surveyor asked for a sample of the schedule they provided to patients. The Administrator stated they and would add the required schedule to the admission documents. The surveyor asked who was responsible for ensuring all the required documents were in the patient’s admission folders. The Administrator stated that it was her responsibility, and she had delegated that recently and the Administrator would do them again. Review of agency policy and procedures found no policy and procedure directing the agency staff and contractors in providing a schedule of services.”