Providence at Home With Compassus Home Health, King

“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 discharged patient data to the Centers for Medicare and Medicaid Services (CMS) database in a timely manner for 13,012 assessments transmitted between 10/01/23 and 10/01/24. Failure to transmit patient data timely could result in inaccurate data and cause delays for patients to receive full benefits. Findings included: 1. As part of the pre-survey preparation, the Surveyors reviewed the “HHA Error Summary by Agency” report transmitted between 08/01/23 through 07/31/24 generated from the iqies.cms.gov website. The review showed that the agency had 13,317 assessments transmitted that were not submitted in a timely manner. This resulted in a 4.46% late submission error rate. 2. On 10/22/24 at 8:30 AM, Surveyor #1 reviewed a document provided by the agency on their OASIS error data. The review showed that the agency had 13,012 assessments transmitted between 10/01/23 through 10/01/24, and that the -3330 error rate was 3.97%. 3. Document review of the agency’s policy titled, “HH OASIS Data Transmission 500-7 (Policy ID 16003452, Last revised: 08/2024) showed the organization will encode and electronically transmit completed OASIS data to the CMS system within thirty days of completing the assessment of the patient. 4. On 10/24/24 at 12:00 PM, Surveyor #1 interviewed the Branch Director (Staff #116) regarding the error rate. Staff #116 stated that the agency was not aware of any late submission errors, and they regularly review the submission report from their electronic medical records (EMR) vendor. Staff #116 stated that they will make changes in their workflow processes to be in compliance. .”

“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 document review, record reviews, and interview, the agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) data for M0104 and M0102 for 5 of 17 patients (Patient #104, Patient #105, Patient #108, Patient #110, and Patient #111). 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. Document review of the agency’s job aide titled, “HH Oasis Data Transmission 500-7,” (Policy ID 16003452, Last revised: 08/2024) showed all encoded OASIS date should accurately reflect the patient’s status at the time the assessment was completed. 2. Record review of patient records for Patient #104, Patient #105, Patient #108, Patient #110, and Patient #111 showed: a. Patient #104 was admitted for the primary diagnosis of Inflammatory condition of the jaw—not a complete list. The OASIS M0104 data showed a date of 04/01/24 rather than the accurate referral date of 04/02/24. Documentation showed the referral was completed on 04/02/24 for Skilled Nursing (SN) Services. b. Patient #105 was admitted for the primary diagnosis of Peripheral Neuropathy—not a complete list. The OASIS M0104 data showed a date of 10/05/24 rather than the accurate referral date of 10/07/24. Documentation showed the referral was completed on 10/07/24 for Physical Therapy (PT)Services. c. Patient #108 was admitted for the primary diagnosis of Hypertension—not a complete list. The OASIS M0104 data showed a date of 09/27/24 rather than the accurate referral date of 09/26/24. Documentation showed the referral was completed on 09/26/24 for PT Services. d. Patient #110 was admitted for the primary diagnosis of Parkinsons—not a complete list. The OASIS M0102 data showed a date of 09/25/24 rather than the specific doctor’s order date of 09/24/24. There was no documentation to show why the OASIS M0102 was documented as 09/25/24 rather than the doctor’s order date of 09/24/24. e. Patient #111 was admitted for the primary diagnosis of Fracture of the Lumbar—not a complete list. The OASIS M0104 showed a date of 09/20/24 rather than the accurate referral date of 09/23/24. Documentation showed the referral was completed on 09/23/24 for SN services. 3. On 10/24/24 at 9:00 AM, Surveyor #1 interviewed the agency’s Clinical Manager (Staff #117) about the inaccurate data entered for OASIS M0104 and M0102. Staff #117 acknowledged the inaccurate documentation of the OASIS data by clinicians but were unable to provide any documentation. .”

“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 document review, record reviews, and interview, the agency failed to communicate with the patient’s physician of SN missed visits resulting in changes to the patient’s plan of care in 2 of 17 patients (Patient #102 and Patient #115). Failure to communicate with the patient’s physician of changes to the plan of care may have a clinical impact on the patient’s wellbeing. Findings included: 1. Review of the agency’s documents showed: a. Document titled, “HH Care Planning Process 203-1,” (Policy ID: 10790601, Last Revised 11/2023) showed individualized plan of care includes frequency of visits. b. Document titled, “HH Missed Visits 208-1 (Policy ID: 14835358, last Revised 12/2023) showed if a visit is missed for any reason, the clinician should attempt to reschedule it. If the visit is missed and not rescheduled the clinician will notify the provider and document the missed visit in the patient’s clinical record. 2. Record review of Patient #102 and Patient #115 records showed: a. Patient #102 was admitted on 03/01/24. Skilled Nursing (SN) services with a frequency of 1 to 3 visits every week for 2 weeks, then 1 to 3 visits every week for 7 weeks starting 03/10/24. SN documentation showed orders 3 times a week and 3rd visit missed. There was no documentation as to why the 3rd SN visits were missed, and no physician notification of these SN missed visits. b. Patient #115 was admitted on 03/06/24. SN services with frequency of 1 to 3 visits every week for 2 weeks starting 03/06/24, then 1 to 2 weeks for 7 weeks starting 03/17/24. During the Medicare weeks of 03/17/24 to 03/23/24, 03/24/24 to 03/30/24, 03/31/24 to 04/06/24, 04/07/24 to 04/13/24, 04/14/24 to 04/20/24, and 04/21/24 to 04/27/24, the patient received no SN visits. In addition, there was no documentation as to why the SN visits were not made, and no physician notification of the missed visit. 3. On 10/24/24 at 10:00 AM, Surveyor #1 interviewed the agency’s Clinical Manager (Staff #117) regarding the lack of documentation and physician notification of the SN missed visits. Staff #117 acknowledged the findings and was not able to provide documentation as to why the SN missed visits did not occurred and why the patients’ physicians were not notified of the missed visits. .”

“Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This Standard is not met as evidenced by: . Based on record review and interview, the agency failed to update and operationalize its policies and procedures to remain in compliance with state licensing requirements for 7 of 15 personnel files reviewed (Staff #602, #603, #604, #606, #610, #612, and #613). Failure to update and implement policies and procedures consistent with the state home health regulations puts patients at risk of physical and/or psychological harm from inadequate or substandard care. . Findings included: References: Washington Administrative Code (WAC) 246-335-525 (6): Criminal history background checks and disclosure statements for personnel, contractors, volunteers, students, and any other individual associated with the licensee having direct contact with children under sixteen years of age, people with developmental disabilities or vulnerable persons, according to RCW 43.43.830 through 43.43.842 and the following: (a) Criminal history background checks must be processed through the Washington State Patrol; (b) Disclosure statements must be approved by the department; and (c) All criminal history background checks and disclosure statements required under this chapter must be renewed within two years from the date of the previous check. WAC 246-335-530 Personnel, contractor, and volunteer records. The licensee must maintain records on all personnel and volunteers and have access to records on all contractors, to include: (7) Evidence of initial and subsequent criminal history background checks and disclosure statement(s) according to RCW 43.43.830 through 43.43.842 and this chapter. 1. Document review of the agency policy titled, “Background Check and Excluded Individual Policy,” (Policy No. KB0053431, Reviewed Date 11/22/2023) showed that the policy failed to include the requirements to process the criminal background checks through the Washington State Patrol and complete the department-approved disclosure statement on personnel and contractors upon hire and within two years of the previous check. 2. The review of the personnel and contractor files showed the following: a. Staff #602 was hired on 10/14/19. The record contained no evidence that the agency completed the state-approved disclosure statement in 2021. b. Staff #603 was hired on 09/22/21. The record contained no evidence that the agency completed the state-approved disclosure statement in 2021. c. Staff #604 was hired on 08/15/19. The record contained no evidence that the agency completed the state-approved disclosure statement in 2023. d. Staff #606 was hired on 08/15/21. The record contained no evidence that the agency completed the state-approved disclosure statement in 2021. e. Staff #610 was hired on 07/11/16. The record contained no evidence that the agency completed the state-approved disclosure statement in 2022. f. Staff #612 was hired as a contracted employee on 09/30/24. The record contained no evidence that the agency completed the state-approved disclosure statement on hire. g. Staff #613 was hired as a contracted employee on 05/08/23. The record contained no evidence that the agency completed the criminal background check through the Washington State Patrol and the state-approved disclosure statement on hire. 3. On 10/24/24 at 12:00 PM, Surveyor #6 interviewed the agency’s Home Health Director (Staff #616) about the missing initial criminal background check and the state-approved disclosure statements in the staff files. Staff #602 acknowledged the findings and stated that they were unable to provide the documentation for the staff listed above. .”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: . Based on document review, record reviews, and interview, the agency failed to conduct the initial assessment visit within the 48 hours of completing the referral and notifying patients or their legal representative of the delayed services for 7 of 17 patients (Patient #104, Patient #105, Patient #107, Patient #108, Patient #111, Patient #112, and Patient #115). Failure to meet this requirement places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Document review of agency’s policy titled, “HH Admission Criteria and Process 201-2,” (Policy ID 16383584, Last Reviewed: 09/2024) showed the initial assessment will be conducted within 48 hours of acceptance of referral information. 2. Record review of patient records Patient #104, Patient #105, Patient #107, Patient #108, Patient #111, Patient #112, and Patient #115 showed: a. Patient #104’s Start of Care (SOC) date was 04/07/24. The patient was admitted for a primary diagnosis of Inflammatory Condition of the Jaw. The agency completed the referral on 04/02/24 for a Registered Nurse (SN) initial assessment, and the SOC for SN services did not occur until 04/07/24. There was no documentation that the patient or their physician were notified of the delayed RN services within 48 hours of the referral date. b. Patient #105’s SOC date was 10/08/24. The patient was admitted for a primary diagnosis of Peripheral Neuropathy. The agency completed the referral on 10/05/24 for a Physical Therapy (PT) initial assessment, and the SOC for PT services did not occur until 10/08/24. There was no documentation that the patient or their physician were notified of the delayed PT services within 48 hours of the referral date. c. Patient #107’s SOC date was 10/19/24. The patient was admitted for a primary diagnosis of Low Backpain and Dementia. The agency completed the referral on 10/16/24 for a PT initial assessment, and the SOC for PT services did not occur until 10/19/24. There was no documentation that the patient or their physician were notified of the delayed PT services within 48 hours of the referral date. d. Patient #108’s SOC date was 10/01/24. The patient was admitted for primary diagnosis of Parkinson’s. The agency completed the referral on 09/26/24 for a PT initial assessment, and the SOC for PT services did not occur until 10/01/24. There was no documentation that the patient or their physician were notified of the delayed PT services within 48 hours of the referral date. e. Patient #111’s SOC date was 09/24/24. The patient was admitted for a primary diagnosis of Fracture of the Lumbar. The agency completed the referral on 09/20/24 for an initial SN assessment, and the SOC for SN services did not occur until 09/24/24. There was no documentation that the patient or their legal representative were notified of the delayed SN services within 48 hours of the referral date. f. Patient #112’s SOC date was 10/19/23. The patient was admitted for a primary diagnosis of Type 2 Diabetes Mellitus. The agency completed the referral on 10/16/23 for an initial SN assessment, and the SOC for SN services did not occur until 10/19/23. There was no documentation that the patient or their legal representative were notified of the delayed SN services within 48 hours of the referral date. g. Patient #112’s SOC date was 10/19/23. The patient was admitted for a primary diagnosis of Type 2 Diabetes Mellitus. The agency completed the referral on 10/16/23 for an initial SN assessment, and the SOC for SN services did not occur until 10/19/23. There was no documentation that the patient or their legal representative were notified of the delayed SN services within 48 hours of the referral date. 3. On 10/22/24 at 10:00 AM, Surveyor #1 interviewed the agency’s Clinical Manager (Staff #117) regarding the lack of documentation that the patient or their legal representative were notified of the delayed SOC services. Staff #117 acknowledged the findings and stated that the referral department attempts to notify the patient or their legal representative of the delayed SOC but was not able to provide documentation. .”

“Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient’s strengths, goals, and care preferences, including information that may be used to demonstrate the patient’s progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This Element is not met as evidenced by: . Based on document review, record reviews, and interview, the agency failed to show that the patient’s strengths and goals were assessed on the initial comprehensive assessment for 4 of 17 patients (Patient #106, Patient #107, Patient #111, and Patient #115). Failure to establish the patient’s strengths and goals prevent patients from achieving their individualized home health goals. Findings included: 1. Document review of agency’s policy titled, “HH Care Planning Process 203-1,” (Policy ID 10790601, Last Revised 11/2023) showed based on the assessment, the plan of care will include reasonable, measurable, and individualized goals and outcomes. 2. Record review of the patient’s initial assessment for Patient #106, Patient #107, Patient #111, and Patient #115 showed no documentation that the agency identified the patients’ individualized goals and outcomes during the comprehensive assessment of each of the patients. 3. On 10/22/24 at 4:00 PM, Surveyor #1 interviewed the agency’s Clinical Manager (Staff #117) regarding the lack of patients’ individualized goals and outcomes during the initial comprehensive assessment. Staff #117 acknowledged the findings and stated that clinicians do establish the patient’s individualized goals and outcomes during the initial assessment visit but was not able to provide documentation. .”