Signature Healthcare at Home

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: . Based on document review and interview, the agency failed to conduct the initial assessment visit within 48 hours of completing the referral (repeated non-compliance from previous surveys) and failed to complete the comprehensive assessment within 5 calendar days of the patients’ start of care. Failure to conduct initial assessments within 48 hours of completing the referral and failure to complete a comprehensive assessment within 5 calendar days of the patients’ start of care puts patients at risk of physical harm due to not receiving services in a timely manner. Findings included: 1. Failure to conduct the initial assessment visit within 48 hours of completing the referral and notifying patients or their legal representative of the delayed services for 5 of 17 patients. 2. Repeated non-compliance identified in recertification surveys conducted 01/30/18 (Under Tag 0332) and 08/12/21 for completion of the initial assessment visit within 48 hours of completing the referral: a. The agency was previously cited on the survey dated 01/03/18 under Tag G0332, Initial Assessment Visit, 42.CFR 484.55(a)(1), for failure to do the initial assessment within forty-eight hours of referral, or forty-eight hours of the patient’s return home, or on the physician-ordered start of care date. b. The agency was previously cited on the survey dated 08/12/21 under Tag G0514, RN Performs Assessment, 42 CFR 484.55(a)(1), for failure to conduct the initial assessment visit within the forty-eight hours of completing the referral and notifying patients or their legal representative of the delayed services. 3. Failure to complete a comprehensive assessment within 5 calendar days of the patients’ start of care for 3 of 10 active patients. Based on the scope and severity of deficiencies identified under 42 CFR 484.55 Condition of participation: Comprehensive assessment of patients is NOT MET. Cross Reference: G0514, G0520 .”

“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 M0102 that requires notifying the physician and obtaining a physician order for an updated Start of Care (SOC) date for 7 of 17 patients (Patients #101, #102, #105, #106, #109, #113, and #114). 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 policy titled, “OASIS Data Transmission,” (Policy No. 3-019.1 Revised Date: 11/2020) showed that the agency will adhere to all OASIS data transmission requirements as outlined in the Medicare Conditions of Participation, Report of OASIS information 42 CFR 484.45. 2. Record review of patient records for Patients #101, #102, #105, #106, #109, #113, and #114 showed: a. Patient #101 was admitted on 03/20/24 with the primary diagnosis of Pneumonia. The referral was completed on 03/15/24 for a Skilled Nursing (SN) initial assessment. Documentation showed the M0102 delayed date of 03/20/24. There is no documentation to show that the physician was notified, or a physician’s order was obtained for the delayed SOC date. b. Patient #102 was admitted on 02/27/24 with the primary diagnosis of Acute Kidney Failure. The referral was completed on 02/20/24 for a Physical Therapy (PT) initial assessment. Documentation showed the M0102 delayed date of 02/27/24. There is no documentation to show that the physician was notified, or a physician’s order was obtained for the delayed SOC date. c. Patient #105 was admitted on 02/16/24 with a primary diagnosis of Status Post Spinal Surgery. The referral was completed on 02/13/24 for a SN initial assessment. Documentation showed the M0102 delayed date of 02/16/24. There is no documentation to show that the physician was notified, or a physician’s order was obtained for the delayed SOC date. d. Patient #106 was admitted on 03/26/24 with a primary diagnosis of Acute Renal Failure. The referral was completed on 03/23/23 for a SN initial assessment. Documentation showed the M0102 delayed date of 03/26/24. There is no documentation to show that the physician was notified, or a physician’s order was obtained for the delayed SOC date. e. Patient #109 was admitted on 11/20/23 with a primary diagnosis of Multiple Sclerosis. The referral was completed on 11/15/23 for a SN initial assessment. Documentation showed the M0102 delayed date of 11/20/23. There is no documentation to show that the physician was notified, or a physician’s order was obtained for the delayed SOC date. f. Patient #113 was admitted on 12/14/22 with a primary diagnosis of Alzheimer’s. The referral was completed on 12/09/22 for a SN initial assessment. Documentation showed the M0102 delayed date of 12/14/22. There is no documentation to show that the physician was notified, or a physician’s order was obtained for the delayed SOC date. g. Patient #114 was admitted on 01/30/23 with a primary diagnosis of Peripheral Vascular Disease. The referral was completed on 01/20/23 for a SN initial assessment. Documentation showed the M0102 delayed date of 01/30/23. There is no documentation to show that the physician was notified, or a physician’s order was obtained for the delayed SOC date. 3. On 04/10/24 at 10:00 AM, Surveyor #1 interviewed the agency’s Administrator (Staff #101) about the lack of physician notification and physician orders for the OASIS M0102. Staff #101 acknowledged the lack of documentation of the OASIS data. Staff #101 stated that the referral staff notifies the physician and obtains the orders for the delayed start of care date for M0102. .”

“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, observation and interview, the agency failed to document patient-specific measurable outcomes as a result of the individualized wound care the patient received for 5 of 17 patients (Patient #306, #308, #309, #311, and #316). Failure to document patient-specific measurable outcomes specifically related to wound care, may place patients at risk of wounds not progressing towards achieving the goals established in the plan of care. Findings included: 1. Document review of the agency’s policy and procedure titled, “Home Health Non-Surgical Wound Care Process,” dated 12/28/23, showed that wounds are to be measured and recorded on all Start of Care, Resumption of Care, and Recertification visits in addition to scheduled weekly measurements. Wounds are to be photographed on all Start of Care, Resumption of Care, and Recertification visits and any time there is significant change. 2. Record review of 5 patient records showed the following: Patient #306 Patient #306 was admitted to home health services on 03/26/24 for wound care to chronic ulcers on right ankle and right lower leg. Patient #306 received skilled nursing visits twice weekly for wound care. The record showed no evidence of weekly wound measurements since the start of care visit on 03/26/24. On 04/09/24 at 1:00 PM, Surveyor #3 completed a home visit with a Licensed Practical Nurse (Staff #303) to Patient #306. During the home visit, Patient #306 reported new wounds to bilateral inner thighs. Staff #303 had received a verbal order to provide wound care to the new wounds. Staff #303 did not measure or photograph the new wounds identified during the visit. During the home visit, Surveyor #3 interviewed Staff #303 about the agency’s policy describing how often staff measure and photograph wounds. Staff #303 stated that wounds are measured weekly but that they did not measure the new wounds during the visit due to the location of the wounds and the patient’s difficulty with standing for an extended period of time. Patient #308 Patient #308 was admitted to home health services on 04/05/23 for wound care to chronic ulcer on right heel, Type 2 Diabetes Mellitus with foot ulcer. Surveyor #3 reviewed the patient record for the following episodes: 04/05/23 to 06/03/23, 06/04/23 to 08/02/23, and 03/30/24 to 05/28/24 as well as the Recertification visits for each episode since the start of care. Patient #308 received skilled nursing visits 3 times per week for wound care. The record showed a buddy code attached weekly to the skilled nursing visits for Wound Measurements Due and Wound Images Due. The buddy code is used by the agency’s electronic medical record system to indicate that a specific task is due that visit. These weekly buddy codes were documented as completed; however, there was no evidence of weekly wound measurements in the visit notes or images for the following weeks: 04/09/23 05/14/23 05/21/23 06/04/23 06/18/23 03/31/24 04/08/24 The record also showed no evidence of wound measurements or images on the Recertification visits on 06/02/23, 09/21/23, and 11/29/23 as required in agency policy. There was also no evidence of wound images on the Recertification visit on 07/31/23 and no wound measurements on the Recertification visits on 03/27/24 as required in agency policy. Patient #309 Patient # 309 was admitted to home health services on 11/20/23 for wound care to pressure ulcer on left ankle, cellulitis and multiple sclerosis. Surveyor #3 reviewed the patient record for the following episodes: 11/20/23 to 01/18/24 and 03/19/24 to 05/17/24 as well as the Recertification visit on 03/15/24. Patient #309 received skilled nursing visits twice weekly for wound care. The record showed a buddy code attached weekly to the skilled nursing visits for Wound Measurements Due and Wound Images Due. These buddy codes were documented as completed; however, there was no evidence of weekly wound measurements in the visit notes or images for the following weeks: 11/26/23 12/10/23 12/24/23 03/17/24 03/24/24 03/31/24 04/07/24 The records also showed no evidence of wound measurements or images on the Resumption of Care visit on 01/09/24 and Recertification visit on 01/17/24. The record also showed no evidence of wound images at the Start of Care visit on 11/20/23 and no evidence of wound measurements at the Recertification visit on 03/15/24 as required in agency policy. Patient #311 Patient #311 was admitted to home health services on 12/20/23 for wound care to unspecified open wound to left lower limb, cellulitis to left lower limb and lymphedema. Patient #311 received skilled nursing visits twice weekly for wound care. The records showed a buddy code attached weekly to the skilled nursing visits for Wound Measurements Due and Wound Images Due. These buddy codes were documented as completed; however, there was no evidence of weekly wound measurements in the visit notes or images for the following weeks: 12/24/23 01/07/24 01/14/24 01/28/24 02/04/24 02/11/24 02/18/24 03/10/24 03/24/24 The record also showed no evidence of wound measurements or images on the Start of Care visit on 12/20/23. The record also showed no evidence of wound measurements or images at the Recertification visit on 02/16/24 as required in agency policy. Patient #316 Patient #316 was admitted for home health services on 01/12/23 with primary diagnosis of Type 2 Diabetes Mellitus, Chronic AFib and Hypertension (not a complete list). Physical therapy completed the initial comprehensive assessment on 01/12/23. The comprehensive assessment showed a stage 1 pressure ulcer to the left lower buttock and a stage 1 pressure ulcer to the right lower buttock with no wound measurements or images. The Registered Nurse (RN) completed an evaluation visit on 01/13/23. The record showed that the RN measured the wounds and provided wound care. The record showed no evidence of wound measurements or images since the skilled nurse evaluation visit. Skilled nursing discharged Patient #316 on 03/09/23 and indicated that no measurements were completed due to “unable to” and that wound care was not provided due to “caregiver completed care”. 3. On 04/10/24 at 11:00 AM, Surveyor #3 interviewed the agency’s Administrator (Staff #301) about the agency’s policy for wound measurements and photographs. Staff #301 stated that the agency measures wounds weekly and records the measurements either in the visit note wound section or narrative section. Staff #301 also stated that wound images are uploaded into the patient’s record as an attachment, but it was recently discovered that they were not being uploaded. Surveyor #3 also asked Staff #301 about the discrepancy between the documentation in the buddy codes indicating completion, and the lack of documented evidence in the visit notes that the clinician completed wound imaging and measurement. Staff #301 stated that the agency’s electronic medical record system does not allow the clinician to document that wound measurements or images were not completed in the buddy code notes. Therefore, all the buddy code notes show that wound measurements and images were completed even when the clinician did not measure and record or photograph the wound.”

“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 48 hours of completing the referral and notifying patients or their legal representative of the delayed services for 5 of 17 patients (Patients #101, #102, #109, #114, and #116). 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, “Initial and Comprehensive Assessment,” (Policy No. 4-018.1, Last Revised: 01/23/24) showed the initial assessment will be conducted within 48 hours of the complete referral. 2. Record review of patient records Patients #101, #102, #109, #114, and #116 showed: a. Patient #101’s Start of Care (SOC) date was 03/20/24. The patient was admitted for primary diagnosis of Pneumonia. The agency completed the referral on 03/15/24 for a Skilled Nursing (SN) initial assessment, and the SOC for the SN services did not occur until 03/20/24. There was no documentation that the patient or their legal representative were notified of the delayed of SN services within the 48 hours of the referral date. b. Patient #102’s SOC date was 02/27/24. The patient was admitted for primary diagnosis of Acute Kidney Failure. The agency completed the referral on 02/20/24 for a Physical Therapy (PT) initial assessment, and the SOC for PT services did not occur until 02/27/24. There was no documentation that the patient or their legal representative were notified of the delayed of PT services within the 48 hours of the referral date. c. Patient #109’s SOC date was 11/20/23. The patient was admitted for primary diagnosis of Multiple Sclerosis. The agency completed the referral on 11/15/23 for a SN initial assessment, and the SOC for SN services did not occur until 11/20/23. There was no documentation that the patient or their legal representative were notified of the delayed of SN services within the 48 hours of the referral date. d. Patient #114’s SOC date was 01/30/23. The patient was admitted for primary diagnosis of Peripheral Vascular Disease. The agency completed the referral on 01/20/23 for a SN initial assessment, and the SOC for SN services did not occur until 01/30/23. There was no documentation that the patient or their legal representative were notified of the delayed of SN services within the 48 hours of the referral date. e. Patient #116’s SOC date was 12/21/22. The patient was admitted for a primary diagnosis of Diabetes Mellitus. The agency completed the referral on 12/05/22 for a PT initial assessment, and the SOC for SN services did not occur until 12/21/22. There was no documentation that the patient or their legal representative were notified of the delayed of PT services within the 48 hours of the referral date. 3. On 04/10/24 at 10:00 AM, Surveyor #1 interviewed the agency’s Administrator (Staff#101) regarding the lack of documentation that the patient or their legal representative were notified of the delayed SOC services. Staff #101 acknowledged the findings and stated that the referral department attempts to notify the patient or their legal representative within 48 hours of the complete referral. THIS IS A REPEAT CITATION: PREVIOUSLY CITED UNDER TAG G0514 (08/12/21) AND TAG G0332 (01/30/18). .”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record reviews and interview, the agency failed to complete the comprehensive assessment that included therapy evaluations within five calendar days of the start of care date for 3 of 10 active patients (Patient #101, #107, and #110). Failure to address the patient’s therapy needs timely puts patients a risk of injury and harm. Findings included: 1. Document review of the agency’s policy titled, “Admission Criteria and Process,” (Policy No. 2-003.1, Last Revised 12/15/23) showed the comprehensive assessment must be completed within five calendar days of the patient’s start of care. Each patient must receive a patient-specific comprehensive assessment that identifies the patient’s nursing and rehabilitative needs. 2. Record review of the patient’s comprehensive assessment for Patient #101, #107, and #110 showed: a. Patient #101’s referral was completed on 03/15/24 with orders for Skilled Nursing (SN) initial assessment, Physical Therapy (PT) evaluation, and Occupational Therapy (OT) evaluation. The SN assessment was completed on the SOC date of 03/20/24. The PT evaluation was completed on 03/29/24, and the OT evaluation was completed on 04/08/24. There is no documentation to show why PT and OT evaluations were not completed within five days of the start of care. b. Patient #107’s referral was completed on 03/08/24 with orders for SN initial assessment, PT evaluation, and OT evaluation. The SN assessment was completed on the SOC date of 03/11/4. The PT evaluation was completed on 03/13/24, and the OT evaluation was completed on 04/03/24. There is no documentation to show why the OT evaluation was not completed within five days of the start of care. c. Patient #110’s referral was completed on 03/15/24 with orders for a SN initial assessment, PT evaluation, and OT evaluation. The SN assessment was completed on the SOC date of 03/18/24. The PT evaluation was completed on 04/09/24, and the OT evaluation was completed on 04/04/24. There is no documentation to show why PT and OT evaluations were not completed within five days of the start of care. 3. On 04/10/24 at 10:30 AM, Surveyor #1 interviewed the agency’s Administrator (Staff #101) regarding the delayed therapy evaluations. Staff #101 acknowledged the findings and stated that the agency makes every attempt to complete therapy evaluations timely. .”