Glovis 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 electronically transmit the completed Outcome and Assessment Information Set (OASIS) assessment for 208 of 287 of assessments reviewed to the state agency within 30 days of completing the OASIS assessment of the patient. Failure of the agency to transmit OASIS data within the required time frame prevented the agency’s patient data from being made available to Centers for Medicare & Medicaid Services (CMS) for analysis to identify agency performance levels in the provision of patient care. Findings: The surveyor reviewed the OASIS transmission report for the agency on the Internet Quality Improvement and Evaluation System (IQIES an internet-based system that includes survey and certification functions) portal on 12/06/2024, as part of the preparation for the survey. The Home Health Agency Error Summary by Agency report revealed 208 assessments were submitted late over a 12-month period out of 287 assessments submitted. In an interview with the Administrator on 12/10/2024 at approximately 10:26 AM, the surveyor requested the Centers for Medicare & Medicaid Services (CMS) OASIS Agency Final Validation report for the last 12 months and asked who was responsible for the Oasis transmissions. The Administrator said, “Me and the Alternate Administrator/Director of Nursing are responsible for the Oasis transmissions.” The surveyor reviewed the OASIS Agency Final Validation reports provided by the Administrator on 12/11/2024. The agency Oasis Agency Final Validation report documented: The report documented the date of the Admission Assessment as entered by the agency at OASIS assessment item M0090 (Oasis coding used to determine the last date that information used to complete the assessment completed) was submitted more than 30 days after the M0090 date for 37 different patients. The report documented the following error message: “Record submitted late: The submission date is more than 30 days after M0090 on this new record.” An interview was conducted with the Administrator on 12/11/2024 at 2:50 PM. The surveyor reviewed the Centers for Medicare & Medicaid Services (CMS) OASIS Agency Final Validation report provided the agency with the Office Manager and Alternate Administrator/Director of Nursing. The surveyor reviewed the findings of the late transmission of the assessments. The surveyor asked why the Oasis were transmitted late by the agency. The Administrator stated, “It was an oversight. Medicare contacted the agency about the errors. Our payments from Medicare will be reduced because of the errors. We are working on correcting the errors.””

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to enforce written policies to control infections and communicable diseases that included requirements to document infections that the patient acquires while receiving services from the agency for one of one active patients (Patient #1) receiving antibiotic treatment. This deficient practice places the active patients at risk of receiving inadequate care and services from the agency’s inability to monitor and trend infections and antibiotic use while receiving care from the agency. The findings included: Review of Patient #1’s medical record revealed Plan of Care signed and dated by Registered Nurse (RN) A and dated 10/17/2024 with a start of care date 10/1/24 for certification period from 10/1/24 through11/29/24 with a principal diagnosis of Type 2 diabetes mellitus with foot ulcer (formerly known as adult-onset diabetes, is a form of diabetes mellitus that is characterized by high blood sugar, insulin resistance, and relative lack of insulin. A diabetic ulcer describes a slow-healing wound that commonly appears on the feet) and a SN frequency of 1 time a week for one week, three times a week for six weeks with three as needed visits (PRN). The plan of care read in part, “SN to perform wound care to Right foot lateral plantar diabetic ulcer…Apply Tetracyte (a topical antibiotic that treats a variety of bacterial infections, including those associated with acne, cuts, scrapes, burns, and chronic wounds) …” Review of the Physician’s Order dated 12/5/24 revealed “ Apply Tetracyte and medical grade honey to the wound bed. Cover with non-bordered foam dressing 2x weekly and as needed (PRN) for soiled or loose dressing…” Review of the Infection Control Log revealed no documented evidence that a review form was completed for Patient #1. During an interview with Registered Nurse (RN) A on 12/12/2024 at 1:55 PM. The surveyor reviewed the above findings. The surveyor asked was an infection control report documented. Registered Nurse (RN) A stated, “It was an oversight on my part.” During an interview with the Director of Nursing/Alternate Administrator and the Administrator on 12/12/2024 at 2:47 PM, the surveyor reviewed the findings. The Administrator stated, “It’s the agency’s policy to document patients that were on antibiotics when they were admitted to the agency.” The Director of Nursing/Alternate Administrator stated, “It was an oversight.” Review of the agency’s policy titled “Infection Control Program” dated 050124, revealed “...The Infection Control Program will include…A system that coordinates: .1. Surveillance for the occurrence of an infection 2. Identification of the occurrence 3. Implementing appropriate preventative procedures 4. Implementing appropriate measures to control infection 5. Review of the data collected to evaluate trends, pattern, etc. 6. Reporting the data and any identified trends as appropriate...Documentation completed by all staff will include at a minimum: 1. Date infection was detected 2. Patient’s/patient’s name 3. Primary diagnosis 4. Sign/symptoms 5. Type of infection 6. Pathogen identified if any 7. Treatment...””

“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: THIS IS A CONTINUED DEFICIENCY PREVIOUSLY CITED AT G0442 ON SURVEY DATED 12/15/2021. Based on record review and interview, the agency failed to provide a proper written notice in advance of terminating on-going care in two of two discharged patient records (Patient 9 and 10) reviewed. This failure prevented the Patients from exercising their right to dispute the termination of Medicare-covered services. Findings include: A list of discharged patients was provided by the Administrator on 12/12/2024. The list provided the dates and reason for discharge, including those patients that were discharged with their goals met. Review of the discharged list: Discharged Patient #9: revealed a discharge date 02/12/2024 with discharge reason “Lack of Funds”. Discharged Patient #10: revealed a discharge date 01/08/2024 with discharge reason “Goals Met”. Review of discharge records: Discharged Patient #9 Record review of the electronic medical record (EMR) included a plan of care dated 12/15/2023-02/12/2014. The record contained a discharge Outcome and Assessment Information Set (OASIS) visit on 01/12/2024. The record failed to reveal a discharge notice. Discharged Patient #10 Record review of the electronic medical record (EMR) included a plan of care dated 11/13/2023-01/11/2014. The record contained a discharge Outcome and Assessment Information Set (OASIS) visit on 01/08/2024. The record failed to reveal a discharge notice. During an interview with the Administrator on 12/12/2024 at approximately 10:40 AM the surveyor presented the above findings. The surveyor requested the discharge notices. The administrator stated the notices were kept in a binder and thought the notices were uploaded into the EMR. The administrator provided the discharge notices for patients #9 and #10. Review of discharge notices: Review of the discharge notice revealed a Center for Medicare/ Medicaid Services (CMS) form titled, “Notice of Medicare Non-Coverage” was signed and dated by Patient #9 on 01/23/2024. The form included the incorrect Quality Improvement Organization (QIO), Identifier AA phone contact number XXX-XXX-4227. Patient #9 should have received the notice of appeal that included the correct Quality Improvement Organization (QIO), Identifier CC phone contact number XXX-XXX-0636. Review of the discharge notice revealed a Center for Medicare/ Medicaid Services (CMS) form titled, “Notice of Medicare Non-Coverage” was signed and dated by Patient #10 on 01/01/2024. The form included the incorrect Quality Improvement Organization (QIO), Identifier BB phone contact number XXX-XXX-5442. Patient #9 should have received the notice of appeal that included the correct Quality Improvement Organization (QIO), Identifier CC phone contact number XXX-XXX-0636. During an interview with the Administrator on 12/12/2024 at approximately 11:14 AM the surveyor presented the above findings. The surveyor asked the Administrator, why the discharged patients had not been given the correct contact phone number of the Quality Improvement Organization (QIO) for the patients to appeal the discharge decision prior to when home health services ended. The surveyor and the Administrator reviewed the agency’s Medicare QIO form provided to the discharged patients. The surveyor the Administrator discussed the incorrect phone numbers and the phone number for the QIO. The Administrator stated she was not aware the QIO contact phone number was incorrect. Review of agency policy dated 050124, quoted in part, “Billing Process/Advance Beneficiary Notice/False Claims RI.50…Notice of Medicare Non-Coverage (NOMNC) A. When all Medicare covered home health care is terminated, the Agency may be required to deliver the Notice of Medicare Non-Coverage (NOMNC) (see the Discharge Notices Policy). B. The NOMNC informs the patient/client, or representative, of the right to an expedited determination by a Quality Improvement Organization (QIO) if it is believed that termination of home health services is not appropriate. C. If the QIO decides that Medicare covered care should end and the patient/client, or representative, wishes to continue receiving care from the Agency even though Medicare will not pay, an ABN must be issued to the patient/client since this would be an initiation of noncovered care…” Review of agency policy dated 050224, quoted in part, “Patient/Client Transfer, Discharge, and Agency Dissolution PE.25… II. Discharge… G. 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. I. The Agency will provide the Advance Beneficiary Notice (ABN) according to the procedures in the Billing Process/Advance Beneficiary Notice/False Claims policy.…” Review of agency policy dated 050124, quoted in part, “Patient/Client Transfer and Discharge Notices PE.30… IV. The Agency will deliver a Detailed Explanation of Non-Coverage (an OMB-approved Medicare form) to the patient/client and the appropriate Quality Improvement Organization (QIO) if the patient/client requests an expedited review by the QIO of the decision that coverage for items and/or services should end…””