Providence at Home With Compassus, Puget Sound South

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on record reviews, and interview, the agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) data for M0102 and M0104 for 4 of 17 patients (Patient #301, #308, #311, and #312). Failure to accurately complete the OASIS data places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Review of 4 of 17 patient records showed the following: a. Patient #301 was admitted on 10/26/23 with the primary diagnosis of unspecified fracture T7-T8 vertebrae. The referral was completed on 10/18/23 for Physical Therapy, Occupational Therapy, and Home Health Aide services. Documentation showed that on 10/24/23 the agency received a delayed start of care order for 10/26/23. The OASIS assessment showed an incorrect M0104 date entered as 10/11/23. b. Patient #308 was admitted on 07/10/24 with a primary diagnosis of hemiplegia hemiparesis following cerebral infarction affecting right dominant side. The referral was completed on 06/27/24. Documentation showed that the agency received a verbal order for the start of care on 07/05/24. The documentation also showed that on 07/05/24 the patient requested a delayed start of care for 07/10/24 and the agency received an updated physician’s start of care order. The OASIS assessment showed an incorrect M0102 date entered as 07/05/24. c. Patient #311 was admitted on 05/02/24 with a primary diagnosis of hypertensive heart disease with heart failure. The referral was received on 04/29/24 and completed on 04/30/24 when the patient discharged from the hospital. The OASIS assessment showed an incorrect M0104 date entered as 04/28/24. d. Patient #312 was admitted on 02/24/24 with a primary diagnosis of multiple sclerosis. The referral was received on 02/13/24 with a physician’s ordered start of care date of 02/19/24. The documentation showed that the agency was unable to contact the patient on 02/19/24 and notified the provider. The documentation also showed an updated physician’s start of care order for 02/24/24. The OASIS assessment showed an incorrect M0104 date entered as 02/12/24. 2. On 08/07/24 at 2:30 PM, Surveyor #3 interviewed the agency’s Clinical Manager (Staff #302) about the inconsistent and incorrect M0102 and M0104 dates. Staff #302 acknowledged the inconsistent documentation of the OASIS data. Staff #302 stated that agency staff reviews the OASIS data for accuracy prior to submission and that these records must have been missed.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care was followed as ordered by the physician for 5 of 17 patients (Patient #305, #310, #311, #314 and #317). Failure to follow the plan of care, as ordered by the physician, puts the patient at risk of worsening symptoms of existing diagnoses. Findings included: 1. Document review of agency’s policy titled, “HH Missed Visits 208-1,” revised 12/2023, showed that if a visit is missed and not rescheduled the clinician will notify the provider and clinical manager of the missed visit and reason for the missed visit. The clinician will also document in the patient record the date and time of the missed visit, reason for the missed visit, description of any unmet needs and the patient’s needs were met, provider notification including the date and time, provider name, method of notification, and the staff reporting the information. 2. Record review of 5 patient records showed: a. Patient #305 had a start of care date of 11/16/19. The plan of care for the certification period of 06/17/24 to 08/15/24 showed Physical Therapy (PT) visits 1 to 2 visits per week for 4 weeks. The record showed that Patient #305 received no PT visits the week of 07/21/24 and 07/28/24. The record showed no evidence that the patient’s physician was notified of the missed visits. b. Patient #310 had a start of care date of 02/14/24. The plan of care for the certification period of 02/14/24 to 04/14/24 showed Skilled Nursing (SN) visits 1 to 2 visits per week for 4 weeks. starting 02/14/24. The record showed that Patient #310 received no SN visits the week of 02/25/24 and 03/17/24. The records showed no evidence that the patient’s physician was notified of the missed visits. c. Patient #311 had a start of care date of 05/02/24. The plan of care for the certification period 05/02/24 to 06/30/24 showed SN visits 1 to 2 visits every week for 7 weeks and PT visits 1 to 2 visits every 4 weeks. Following a resumption of care, the record showed orders for SN 1 to 2 visits every week for 2 weeks starting and PT 1 to 2 visits every week for 2 weeks starting 06/13/24. The records showed that Patient #311 received no SN visits the week of 06/13/24. The record showed no evidence that the patient’s physician was notified of the missed visits. For the current certification period starting on 07/01/24, the plan of care showed PT visits 1 to 2 visits every week for 9 weeks. The records showed that Patient #311 received no PT visits the week of 07/01/24 and 07/07/24. The record showed no evidence that the patient’s physician was notified of the missed visits. d. Patient #314’s start of Care (SOC) was 01/19/24. The plan of care for the certification period of 01/19/24 to 03/18/24 included SN visits of 1-2 per week for 7 weeks and PT visits of 1-2 per week for 8 weeks. The patient did not receive any SN visits during the Medicare weeks of 02/18/24 to 02/24/24 and 02/25/24 to 03/02/24. In addition, there was no documentation as to why the SN visits were not made and no physician notification of the missed visits. Patient #314’s plan of care for the certification period of 03/19/24 to 05/17/24 included SN visits of 1-2 per week for 7 weeks. The patient did not receive any SN visits during the Medicare weeks of 03/31/24 to 04/06/24 and 04/21/24 to 04/27/24. In addition, there was no documentation as to why the SN visits were not made and no physician notification of the missed visits. e. Patient #317’s SOC was 11/07/23. The plan of care for the certification period of 11/07/23 to 01/05/24 included SN visits of 2-3 per week for 4 weeks, then 1 visit per 30 days for 60 days, PT visits of 2-3 per week for 4 weeks, then 1-3 visits for 5 weeks and, OT visits of 2-3 per week for 4 weeks. The patient did not receive any SN visits during the Medicare week of 11/12/23 to 11/18/23. In addition, there was no documentation as to why the SN visits were not made and no physician notification of the missed visits. 3. On 08/07/24 at 3:00 PM, Surveyor #3 interviewed the agency’s Clinical Manager (Staff #302) about the agency’s policy for missed visits. Staff #302 stated that the clinicians are responsible for completing the missed visits notes that are either faxed to the provider or sent via the “inbox” feature in Epic.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on document review, record review, and interview, the agency failed to inform patients of all aspects of their plan of care, including the total frequency of the proposed services and the manner in which the agency will provide those care and services for 17 of 17 patients (Patient #301, #302, #303, #304, #305, #306, #307, #308, #309, #310, #311, #312, #313, #314, #315, #316, and #317). Failure to inform patients and their representatives of the frequencies of the proposed care and services prevent patients from participating in their care. Findings included: 1. Record review of agency’s document titled, “Home Health Rights/Responsibilities 100-1,” revised 12/2023, showed that the patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care to the patient of the establishment and revision of the plan of care, including disciplines that will furnish the care and the frequency of visits as well as any changes in the care to be furnished. 2. Review of 17 patient records showed the following: a. Patient #301 was admitted to services on 10/26/23. Surveyor #3 reviewed the certification period from 10/26/23 to 12/24/23 and the current certification period from 06/22/24 to 08/20/24. The referral orders showed a visit frequency for Physical Therapy (PT) 1 to 3 visits every week for 2 weeks, Occupational Therapy (OT) 1 to 3 visits every week for 2 weeks, Home Health Aides (HHA) 4 to 6 visits every 30 days and Social Worker (MSW) 1 to 3 visits every 30 days. Additional orders were obtained at the start of care for Physical Therapy 4 to 8 visits every 30 days, and Occupational Therapy 1 to 2 visits every week for 6 weeks. On 11/20/23 the Occupational Therapist received additional orders for 1 to 2 visits every week for 6 weeks. On 11/30/23 the Physical Therapist received additional orders for 3 to 5 visits every 21 days. On 12/07/23 the agency received orders for Home Health Aides 2 visits every week for 2 weeks. For the current certification period from 06/22/24 to 08/20/24, the record showed orders for Physical Therapy 1 to 2 visits per week for 9 weeks and Home Health Aides 1 visit per week for 9 weeks. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for PT, OT and MSW services. On 08/06/24 at 12:30 PM, Surveyor #3 conducted a home visit for Patient #301. Surveyor #3 interviewed Patient #301 about the plan of care and visit frequencies. Patient #301 stated that they were unaware of when the PT or OT planned on seeing them and that they wait for them to call. Patient #301 also stated that they complained to the agency because the PT wanted to decrease the visit frequency to 1 per week and did not notify the patient in advance. b. Patient #302 was admitted to services on 04/03/24. Surveyor #2 reviewed the certification period from 04/03/24 to 06/01/24 and 06/02/24 to 07/31/24. The record showed that standard start of care orders were SN 1 to 3 visits per week for 2 weeks and for PT, 1 to 2 visits per week for 2 weeks. On 04/05/24, the agency received an order for SN 1 visit per week for 7 weeks, PT 1 to 2 visits per week for 7 weeks and OT 1 to 3 visits per week for 9 weeks. For the certification period from 06/02/24 to 07/31/24, the record showed orders for PT 1 to 2 visits per week for 9 weeks. On 07/09/24, the agency received new orders for PT and RN 1 to 3 visits per week for 2 weeks and OT 1 to 2 visits per week for 2 weeks. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for SN, PT and OT services. On 08/06/24 at 11:00 AM, Surveyor #2 conducted a home visit for Patient #302. Surveyor # 2 interviewed the patient and their daughter about the plan of care and visit frequencies. The patient’s daughter stated the visit schedule was not planned in advance and that the agency called them a day before to confirm the visit. c. Patient #303 was admitted to services on 07/06/24. Surveyor #2 reviewed the certification period from 07/06/24 to 09/03/24. The record showed that the standard start of care order was PT 1 to 3 visits for 2 weeks. On 07/14/24, the agency received an order for PT 1 to 2 visits per week for 6 weeks. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for PT. On 08/06/24 at 2:00 PM, Surveyor #2 conducted a home visit for Patient #303. Surveyor # 2 interviewed the patient and their daughter about the plan of care and visit frequencies. The patient’s daughter stated that she was unaware of the visit schedule and frequency of visits. d. Patient #304 was admitted to services on 03/12/24. Surveyor #2 reviewed the certification period from 03/12/24 to 05/10/24 and 07/10/24 to 09/07/24. The record showed that the standard start of care order was PT 1 to 3 visits per week for 2 weeks. Between March 12 to 24, 2024, the agency received new orders for SN 1 to 2 visits per week for 8 weeks, PT 1 to 2 visits per week for 4 weeks, OT 1 to 2 visits per week for 7 weeks, SLP 1-3 visits per week for 2 weeks and HHA 1 visit per week for 9 weeks. On 03/25/24, the agency received new order for SLP 2 to 3 visits within 30 days, then 1 to 2 visits within 12 days from 04/29/24 to 05/10/24. For certification period from 07/10/24 to 09/07/24, the record showed orders for SN 1 visit per week for 9 weeks, OT 5 to 6 visits within 30 days for 60 days, SLP 3 to 4 visits within 30 days for 60 days and HHA 1 visit per week for 9 weeks. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for SN, PT, OT, SLP and HHA services. On 08/07/24 at noon, Surveyor #2 conducted a home visit for Patient #304. Surveyor # 2 interviewed the patient’s husband about the plan of care and visit frequencies. The husband stated that the agency comes once a week, but he is not aware of the frequency and when the next schedule is. Review of the “My Health Journey” folder that the agency provided Patient #304 at the start of care showed no evidence that the clinicians documented the anticipated visit frequency on the Individual Care Plan located in the folder. e. Patient #305 was admitted to services on 11/16/19. Surveyor #3 reviewed the current certification period from 06/17/24 to 08/15/24. The record showed orders for Skilled Nursing (SN) 1 to 3 visits per week for 8 weeks, Physical Therapy (PT) 1 to 2 visits per week for 4 weeks, Occupational Therapy 1 to 2 visits per week for 5 weeks, and Home Health Aides 1 visit per week for 9 weeks. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for SN, PT, and OT services. On 08/07/24 at 10:00 AM, Surveyor #3 conducted a home visit with Patient #305. Surveyor #3 interviewed Patient #305 about the plan of care and visit frequencies. Patient #305 stated that they were unaware of when the therapy planned on seeing them again and that they wait for them to call to schedule the visit. f. Patient #306 was admitted to services on 07/09/24. The record showed start of care orders for Skilled Nursing (SN), Physical Therapy (PT), and Occupational Therapy (OT) 1 to 3 visits per week for 2 weeks. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for SN, PT, OT and MSW services. g. Patient #307 was admitted to services on 08/03/24. The record showed start of care orders for Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), and Social Worker (MSW) 1 to 3 visits per week for 2 weeks. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for SN, PT, OT and MSW services. On 08/07/24 at 12:30 PM, Surveyor #3 conducted a home visit with Patient #307. Surveyor #3 interviewed Patient #307 about the plan of care and visit frequencies. Patient #307 stated that they were unaware of when the clinicians planned on seeing them again and that they wait for them to call to schedule the visit. Surveyor #3 also observed the “My Health Journey” folder that the agency provided Patient #307 at the start of care. The folder showed no evidence that the clinicians documented the anticipated visit frequency on the Individual Care Plan located in the folder. h. Patient #308 was admitted to services on 07/10/24. The record showed the standard start of care orders for Skilled Nursing (SN) and Occupational Therapy (OT) 1 to 3 visits per week for 2 weeks. The record showed additional orders on 07/10/24 for SN 1 to 2 visits per week for 7 weeks and on 07/19/24 for OT 1 to 2 visits per week for 4 weeks. The record also showed an order for Social Worker (MSW) 1 to 4 visits every 30 days. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for SN, PT, and OT services. i. Patient #309 was admitted to services on 06/09/24. The record showed the standard start of care orders for Physical Therapy (PT) and Occupational Therapy (OT) 1 to 3 visits per week for 2 weeks and Skilled Nursing (SN) 2 to 3 visits per week for 4 weeks. The record showed additional orders on 06/16/24 for PT 1 to 2 visits per week for 4 weeks. The record also showed additional OT orders on 06/17/24 for 2 to 3 visits per week for 4 weeks and on 07/14/24 1 to 2 visits per week for 4 weeks. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for SN, PT, and OT services. j. Patient #310 was admitted to services on 02/14/24. Surveyor #3 reviewed the certification period from 02/14/24 to 04/14/24 and the current certification period from 06/13/24 to 08/11/24. The referral orders showed Physical Therapy (PT) and Occupational Therapy (OT) 1 to 3 visits per week for 2 weeks. On 02/14/24 the agency received an order for Skilled Nursing (SN) 1 to 2 visits per week for 4 weeks. On 02/25/24 the agency received additional orders for PT and OT 1 to 2 visits per week for 4 weeks. For the certification period from 06/13/24 to 08/11/24, the record showed orders for Skilled Nursing (SN) 1 to 2 visits every week for 9 weeks, PT 4 to 8 visits every 30 days, and MSW 1 to 3 visits every 30 days. The agency received additional orders for PT to start on 07/14/24 1 to 2 visits per week for 5 weeks. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for SN, PT, OT, and MSW services. k. Patient #311 was admitted to services on 05/02/24. Surveyor #3 reviewed the certification period from 05/02/24 to 06/30/24 and the current certification period from 07/01/24 to 08/30/24. The record showed the standard start of care orders for Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Social Worker (MSW) of 1 to 3 visits per week for 2 weeks. On 05/03/24 the agency received an order for Skilled Nursing (SN) 1 to 2 visits per week for 7 weeks. On 05/14/24 the agency received additional orders for PT 1 to 2 visits per week for 4 weeks. On 05/28/24 the agency received orders for MSW 1 to 3 visits per week for 2 weeks. For the certification period from 07/01/24 to 08/30/24, the record showed orders for Skilled Nursing (SN) and Physical Therapy (PT) 1 to 2 visits every week for 9 weeks. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for SN, PT, OT, and MSW services. l. Patient #312 was admitted to services on 02/24/24. Surveyor #3 reviewed the certification period from 02/24/24 to 04/23/24 and the current certification period from 06/23/24 to 08/21/24. The record showed the standard start of care orders for Skilled Nursing (SN) and Physical Therapy (PT) 1 to 3 visits per week for 2 weeks. On 03/25/24 the agency received an order for Skilled Nursing (SN) 1 to 2 visits per week for 6 weeks. On 03/03/24 the agency received additional orders for PT 2 to 3 visits per week for 3 weeks. For the certification period from 06/23/24 to 08/21/24, the record showed orders for SN 1 to 2 visits every week for 9 weeks and PT 1 to 3 visits every 4 weeks. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for SN and PT services. m. Patient #313 was admitted to services on 01/23/24. Surveyor #2 reviewed the certification period from 01/23/24 to 03/22//24 and 03/23/24 to 05/21/24. The record showed that the standard start of care orders were SN 2 to 3 visits per week for 3 weeks, PT 2 to 3 visits per week for 4 weeks, and OT 1-2 visits per week for 3 weeks. Between February 11 to 19, 2024, the agency received new orders for SN 2 to 3 visits per week for 6 weeks, PT 1 to 2 visits per week for 4 weeks and OT 1 to 2 visits per week for 4 weeks. For certification period from 03/23/24 to 05/21/24, the record showed orders for SN 1 to 2 visits per week for 10 weeks and PT 1 to 2 visits per week for 6 weeks. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for SN, PT and OT. n. Patient #314 was admitted to services on 01/19/24. Surveyor #2 reviewed the certification period from 01/19/24 to 03/18/24 and 03/19/24 to 05/17/24. The record showed that the standard start of care orders were SN 1 to 3 visits per week for 2 weeks, PT 1 to 3 visits per week for 2 weeks and OT 1 to 3 visits per week for 2 weeks. On 01/28/24, the agency received new orders for SN 1 to 2 visits per week for 7 weeks and PT 1 to 2 visits per week for 8 weeks. For the certification period from 03/19/24 to 05/17/24, the record showed an order for SN 1 to 2 visits per week for 8 weeks. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for SN, PT and OT. o. Patient #315 was admitted to services on 02/09/24. Surveyor #2 reviewed the certification period from 02/09/24 to 04/08/24 and 04/09/24 to 06/07/24. The record showed that the standard start of care order was PT 1 to 3 visits per week for 2 weeks. On 02/27/24, the agency received a new order for PT 1 to 3 visits per week for 2 weeks. On 03/10/24, the agency received a new order for PT 1 to 2 visits per week for 5 weeks. For the certification period from 04/09/24 to 06/07/24, the record showed an order for PT 1 to 2 visits per week for 9 weeks. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for PT. p. Patient #316 was admitted to services on 12/04/23. Surveyor #2 reviewed the certification period from 12/04/23 to 02/01/24 and 02/02/24 to 04/01/24. The record showed that the standard start of care orders were SN 1 to 8 visits within 60 days for 60 days, PT 1 to 3 visits per week for 2 weeks and OT 1-3 visits per week for 2 weeks. On 12/18/23, the agency received new orders for PT 1 to 2 visits per week for 7 weeks and OT 2 to 6 visits within 30 days. For the certification period from 02/02/24 to 04/01/24, the record showed orders for SN 3 PRN (as needed) visits and 1 to 3 visits within 30 days for 60 days and PT 1 to 5 visits within 30 days for 60 days. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for SN, PT and OT. q. Patient #317 was admitted to services on 11/07/23. Surveyor #2 reviewed the certification period from 11/07/23 to 01/05/24 and 01/06/24 to 03/05/24. The record showed that the standard start of care orders were SN 2 to 3 visits per week for 4 weeks, PT 2 to 3 visits per week for 4 weeks and OT 2 to 3 visits per week for 4 weeks. On 12/03/23, the agency received new orders for SN 1 visit within 30 days for 60 days, PT 1 to 3 visits per week for 5 weeks and OT 1 to 2 visits per week for 4 weeks. For the certification period from 01/06/24 to 03/05/24, the record showed orders for SN 1 to 2 visits per week for 9 weeks, PT 1 to 2 visits per week for 9 weeks and OT 1 to 2 visits per week for 9 weeks. There was no documentation in the record to show the agency informed the patient or their representative of the varying frequencies ordered for SN, PT and OT. 3. On 08/08/24 at 10:00 AM, Surveyor #3 interviewed the agency’s Home Health Director (Staff #301) about the agency’s use of visit frequency ranges. Staff #301 stated that the agency uses a standard referral order of 1 to 3 visits every week for 2 weeks then the clinicians adjust the orders based upon their assessment findings. Staff #301 stated that they were aware of the lack of documentation that showed the patient or patient representative was informed of the varying visit frequencies at the previous CMS recertification survey. Staff #301 stated that the agency has provided education and training to clinicians regarding the use of varying visit frequencies and documentation in the patient “My Home Health Journey” folder. Staff #301 provided Surveyor #3 with evidence of staff education from 2022 through 07/16/24 regarding using varying frequencies and keeping the patient informed. Staff #301 stated that the agency completes monthly chart audits but does not review the chart for evidence that the patient has been informed of the visit frequency. THIS IS A REPEAT CITATION FROM 10/14/21.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on document reviews and interview, the agency failed to show coordination of care involving the patient, their representative, and their caregivers, as appropriate, in the development and coordination of frequency and duration of visits based on the patient’s needs for 3 of 17 patients (Patient #301, #303, #307). Failure to involve the patient or their representative in the coordination of their care puts the patient’s needs and medical condition at risk for unsafe and poor quality of care. Findings included: 1. Document review of agency’s document titled, “Home Health Rights/Responsibilities 100-1,” revised 12/2023, showed that the patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care to the patient of the establishment and revision of the plan of care, including disciplines that will furnish the care and the frequency of visits as well as any changes in the care to be furnished. 2. Patient #301 was admitted to services on 10/26/23. On 08/06/24 at 12:30 PM, Surveyor #3 conducted a home visit for Patient #301. Surveyor #3 interviewed Patient #301 about the plan of care and visit frequencies. Patient #301 stated that they were unaware of when the PT or OT planned on seeing them and that they wait for them to call. Patient #301 also stated that they complained to the agency because the PT wanted to decrease the visit frequency to 1 per week and did not notify the patient in advance. 3. Patient #303 was admitted to services on 07/06/24. On 08/06/24 at 2:00 PM, Surveyor #2 conducted a home visit for Patient #303. Surveyor # 2 interviewed the patient and the daughter about the plan of care and visit frequencies. The patient’s daughter stated that she was unaware of the visit schedule and frequency of visits. 4. Patient #307 was admitted to services on 08/03/24. On 08/07/24 at 12:30 PM, Surveyor #3 conducted a home visit with Patient #307. Surveyor #3 interviewed Patient #307 about the plan of care and visit frequencies. Patient #307 stated that they were unaware of when the clinicians planned on seeing them again and that they wait for them to call to schedule the visit. Surveyor #3 also observed the “My Health Journey” folder that the agency provided Patient #307 at the start of care. The folder showed no evidence that the clinicians documented the anticipated visit frequency on the Individual Care Plan located in the folder. CROSS REFERENCE TAG G0614 THIS IS A REPEAT CITATION FROM 10/14/21.”

“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 record reviews and interview, the agency failed to provide the patient and caregiver with a written visit schedule consistent with the patient’s most current plan of care for 17 of 17 patients (Patient #301, #302, #303, #304, #305, #306, #307, #308, #309, #310, #311, #312, #313, #314, #315, #316, #317). Failure to provide the patient and caregiver with a copy of the visit schedule and frequency of visits may lead to confusion, missed visits, and a breakdown in the continuity of care, which may negatively affect patient outcomes. Findings included: 1. Document review of agency’s document titled, “Home Health Rights/Responsibilities 100-1,” revised 12/2023, showed that the patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care to the patient of the establishment and revision of the plan of care, including disciplines that will furnish the care and the frequency of visits as well as any changes in the care to be furnished. 2. Record review of care plans for 17 patients showed: a. Patient #301’s Start of Care was 10/26/23. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification periods of 10/26/23 to 12/24/23 and 06/22/24 to 08/20/24. On 08/06/24 at 12:30 PM, Surveyor #3 conducted a home visit for Patient #301. Surveyor #3 interviewed Patient #301 about the plan of care and visit frequencies. Patient #301 stated that they were unaware of when the PT or OT planned on seeing them and that they wait for them to call. Patient #301 also stated that they complained to the agency because the PT wanted to decrease the visit frequency to 1 per week and did not notify the patient in advance. b. Patient #302’s Start of Care was 04/03/24. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification periods of 04/03/24 to 06/01/24 and 06/02/24 to 07/31/24. On 08/06/24 at 11:00 AM, Surveyor #2 conducted a home visit for Patient #302. Surveyor #2 interviewed the patient and the daughter about the plan of care and visit frequencies. The patient’s daughter stated the visit schedule was not planned in advance and that the agency called them a day before to confirm the visit. c. Patient #303’s Start of Care was 07/06/24. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification period of 07/06/24 to 09/03/24. On 08/06/24 at 2:00 PM, Surveyor #2 conducted a home visit for Patient #303. Surveyor #2 interviewed the patient and the daughter about the plan of care and visit frequencies. The patient’s daughter stated that she was unaware of the visit schedule and frequency of visits. d. Patient #304’s Start of Care was 03/12/24. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification periods of 03/12/24 to 05/10/24 and 07/10/24 to 09/07/24. On 08/07/24 at noon, Surveyor #2 conducted a home visit for Patient #304. Surveyor #2 interviewed the patient’s husband about the plan of care and visit frequencies. The husband stated that the agency comes once a week, but he is not aware of the frequency and when the next schedule is. Review of the “My Health Journey” folder that the agency provided Patient #304 at the start of care showed no evidence that the clinicians documented the anticipated visit frequency on the Individual Care Plan located in the folder. e. Patient #305’s Start of Care was 01/04/21. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification period of 06/17/24 to 08/15/24. On 08/07/24 at 10:00 AM, Surveyor #3 conducted a home visit with Patient #305. Surveyor #3 interviewed Patient #305 about the plan of care and visit frequencies. Patient #305 stated that they were unaware of when the therapist planned on seeing them again and that they were wait for them to call to schedule the visit. f. Patient #306’s Start of Care was 07/09/24. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification period of 07/06/24 to 09/06/24. On 08/07/24 at 11:00 AM, Surveyor #2 conducted a home visit for Patient #306. Surveyor #2 interviewed the patient’s caregiver about the plan of care and visit frequencies. The caregiver stated that the agency did not provide information on the frequency of the visits and visit schedule was not planned in advance and that the agency called them a day before to confirm the visit. Review of the “My Health Journey” folder that the agency provided Patient #306 at the start of care showed no evidence that the clinicians documented the anticipated visit frequency on the Individual Care Plan located in the folder. g. Patient #307’s Start of Care was 08/03/24. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification period of 08/03/24 to 10/01/24. On 08/07/24 at 12:30 PM, Surveyor #3 conducted a home visit with Patient #307. Surveyor #3 interviewed Patient #307 about the plan of care and visit frequencies. Patient #307 stated that they were unaware of when the clinicians planned on seeing them again and that they wait for them to call to schedule the visit. Surveyor #3 also observed the “My Health Journey” folder that the agency provided Patient #307 at the start of care. The folder showed no evidence that the clinicians documented the anticipated visit frequency on the Individual Care Plan located in the folder. h. Patient #308’s Start of Care was 07/10/24. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification period of 07/10/24 to 09/07/24. i. Patient #309’s Start of Care was 06/09/24. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification period of 06/09/24 to 08/07/24. j. Patient #310’s Start of Care was 02/14/24. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification periods of 02/14/24 to 04/14/24 and 06/13/24 to 08/11/24. k. Patient #311’s Start of Care was 05/02/24. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification periods of 05/02/24 to 06/30/24 and 07/01/24 to 08/30/24. l. Patient #312’s Start of Care was 02/24/24. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification periods of 02/24/24 to 04/23/24 and 06/23/24 to 08/21/24. m. Patient #313’s Start of Care was 01/23/24. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification periods of 01//23/24 to 03/22/24 and 03/23/24 to 05/21/24. n. Patient #314’s Start of Care was 01/19/24. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification periods of 01/19/24 to 03/18/24 and 03/19/24 to 05/17/24. o. Patient #315’s Start of Care was 02/09/24. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification periods of 02/09/24 to 04/08/24 and 04/09/24 to 06/07/24. p. Patient #316’s Start of Care was 12/04/24. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification periods of 12/04/23 to 02/01/24 and 02/02/24 to 04/01/24. q. Patient #317’s Start of Care was 11/07/23. There was no documentation in the patient’s record that the agency provided a copy of the visit schedule and frequency of visits to the patient or caregiver during the certification periods of 11/07/23 to 01/05/24 and 01/06/24 to 03/05/24. 3. On 08/08/24 at 10:00 AM, Surveyor #3 interviewed the agency’s Home Health Director (Staff #301) about the agency’s use of visit frequency ranges. Staff #301 stated that the agency uses a standard referral order of 1 to 3 visits every week for 2 weeks, and then the clinicians adjust the orders based on their assessment findings. Staff #301 stated that they were aware of the lack of documentation that showed the patient or patient representative was informed of the varying visit frequencies at the previous CMS recertification survey. Staff #301 stated that the agency had provided education and training to clinicians regarding the use of varying visit frequencies and documentation in the patient “My Home Health Journey” folder. Staff #301 provided Surveyor #3 with evidence of staff education from 2022 through 07/16/24 regarding using varying frequencies and keeping the patient informed. Staff #301 stated that the agency completes monthly chart audits but does not review the chart for evidence that the patient has been informed of the visit frequency. THIS IS A REPEAT CITATION FROM 10/14/21.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on record review and interview, the agency failed to document interdisciplinary assessments as described in agency policy for 11 of 19 patients (Patient #301, #302, #304, #305, #310, #311, #312, #313, #314, #316, #317). Failure to conduct interdisciplinary assessments for each patient puts the patient’s needs and medical condition at risk for unsafe and uncoordinated care. Findings included: 1. Record review of the agency’s policy titled, “ HH Case Conference/Progress Summary 204-3,” revised 12/2023, showed that the case conference will be held at least every 60 days to review and discuss all multidisciplinary cases. Each multidisciplinary patient will have a case conference during the month following the certification month. A case conference/progress summary, written by the appropriate discipline treating the patient, will be placed in the patient’s clinical record after each case conference meeting. A copy will be sent to the attending provider. 2. Record review of 11 of 19 patient records showed the following: a. Patient #301 was admitted on 10/26/23. The records showed Patient #301 received Physical Therapy (PT), Occupational Therapy (OT) and Home Health Aide (HHA) services. The record showed no evidence of an interdisciplinary assessment or case conference completed every 60 days as described in agency policy. b. Patient #302 was admitted to services on 04/03/24. The records showed Patient #302 received Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services. The record showed no evidence of an interdisciplinary assessment or case conference completed every 60 days as described in agency policy. c. Patient #304 was admitted to services on 03/12/24. The records showed Patient #304 received Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Speech-Language Pathology (SLP) and Home Health Aide (HHA) services. The record showed no evidence of an interdisciplinary assessment or case conference completed every 60 days as described in agency policy. d. Patient #305 was admitted on 11/06/19. The records showed Patient #305 received Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT) and Home Health Aide (HHA) services. The record showed no evidence of an interdisciplinary assessment or case conference completed every 60 days as described in agency policy. e. Patient #310 was admitted on 02/14/24. The records showed Patient #310 received Physical Therapy (PT), and Occupational Therapy (OT) services. The record showed no evidence of an interdisciplinary assessment or case conference completed every 60 days as described in agency policy. f. Patient #311 was admitted on 05/02/24. The records showed Patient #311 received Physical Therapy (PT), Occupational Therapy (OT) and Social Worker (MSW) services. The record showed no evidence of an interdisciplinary assessment or case conference completed every 60 days as described in agency policy. g. Patient #312 was admitted on 02/24/24. The records showed Patient #312 received Skilled Nursing (SN) and Physical Therapy (PT) services. The record showed no evidence of an interdisciplinary assessment or case conference completed every 60 days as described in agency policy. h. Patient #313 was admitted to services on 01/23/24. The records showed Patient #313 received Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services. The record showed no evidence of an interdisciplinary assessment or case conference completed every 60 days as described in agency policy. i. Patient #314 was admitted to services on 01/19/24. The records showed Patient #314 received Skilled Nursing (SN) and Physical Therapy (PT) services. The record showed no evidence of an interdisciplinary assessment or case conference completed every 60 days as described in agency policy. j. Patient #316 was admitted to services on 12/04/23. The records showed Patient #316 received Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services. The record showed no evidence of an interdisciplinary assessment or case conference completed every 60 days as described in agency policy. k. Patient #317 was admitted to services on 11/07/23. The records showed Patient #317 received Skilled Nursing (SN), Physical Therapy (PT) and Occupational Therapy (OT) services. The record showed no evidence of an interdisciplinary assessment or case conference completed every 60 days as described in agency policy. 3. On 08/08/24 at 12:00 PM, Surveyor #3 interviewed the Clinical Manager (Staff #302) about the agency’s interdisciplinary assessment policy and procedure. Staff #302 stated that the agency discusses each start of care and upcoming recertification or discharge during the weekly IDT meetings. Staff #302 stated that the agency uses a spreadsheet to review patients with upcoming recertifications but that they do not enter a case communication note in the agency’s EMR system. 4. On 08/08/24 at 2:00 PM, Surveyor #3 interviewed the Home Health Director (Staff #301) about the agency’s interdisciplinary assessment policy and procedure. Staff #301 stated that they use a spreadsheet to document recertification patients. Staff #301 also stated that recently a QAPI staff member informed the agency that they need to be entering case communication notes for recertification IDT documentation. Staff #301 provided Surveyor #3 with samples of the spreadsheets used by the agency.”