Jackson Medical Center Home Health

“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 review of CMS (Centers for Medicare and Medicaid Services) HHA (Home Health Agency) Error Summary by Agency Report, CMS OASIS (Outcome and Assessment Information Set) Agency Final Validation Reports, agency policy, and interview with staff, it was determined the agency failed to ensure OASIS data was transmitted to CMS within 30 days after the assessments were completed. This deficient practice affected 504 OASIS assessments and had the potential to affect all OASIS assessments submitted by this agency. Findings include: Agency Policy: OASIS Policy Number: Not Listed Revised/Reviewed: Not Listed 1. Initial Visit Assessment: RN/PT (Registered Nurse/Physical Therapist) to complete OASIS comprehensive assessment on initial visit, but no later than five (5) calendar days after the Start of Care... 4. Quality Staff: Quality Staff must encode, edit, and approve the OASIS information into the computer system within 14 days from the completion by said RN/PT. All information must be transmitted ... no later than 30 days of the assessment date... 1. A pre-survey review of the HHA Error Summary by Agency report for the period from 1/1/24 through 12/31/24 revealed 31.3 % of the OASIS assessments were submitted greater than 30 days after the assessments were completed. A review of the OASIS Agency Final Validation Reports from 1/1/25 through 5/5/25 conducted on 5/8/25 revealed a total number of 381 OASIS assessments were submitted and 170 of those were submitted greater than 30 days after the assessment. Which was a 45 % submitted greater than 30 days after the OASIS assessment. An interview was conducted on 5/8/25 at 1:15 PM with Employee Identifier # 1, Director, who confirmed the agency failed to ensure the OASIS assessments were submitted per agency policy.”

“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 medical record (MR) review, agency policies, and interview with staff, it was determined the agency failed to ensure the Plan of Care (POC) including visit frequencies were followed. This deficient practice did affect one of three MR reviewed of patients receiving Home Health Aide (HHA) services including Home Visit (HV) # 4 and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Plan of Care/Physician Orders Policy Number: Not Listed Revised/Reviewed Date: Not Listed Policy... All interventions and treatments provided by the agency are to be consistent with the plan of care... Agency Policy: Scheduling Visits Policy Number: Not Listed Revised/Reviewed Date: Not Listed Visits are scheduled according to physician orders and patient needs...If a visit is missed...we will try to make up the visit if possible... 1. HV # 4 was admitted on 3/7/25 with diagnoses including Urinary Tract Infection, Hypotension, and Pressure Ulcer of Left Ankle. Review of the Home Health Certification (HHC) and POC dated 3/7/25, included physician’s orders for Home Health Aide (HHA) two visits per week for nine weeks. Review of the Missed Visit notes dated 3/11/25, 3/14/25, 3/20/25, 3/28/25, 4/1/25, 4/3/25, 4/15/25, 4/18/25, 4/29/25, and 5/1/25 and signed by the HHA revealed the HHA documented the visits were missed. There was no documentation the nurse was notified, no documentation attempts were made to re-schedule the visits, and no documentation the nurse notified the physician. An interview was conducted on 5/8/25 at 1:15 PM with Employee Identifier # 1, Director, who confirmed the agency failed to ensure the visit frequency for HHA was followed.”