Holistic Approach 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 interview and record review, the agency failed to ensure the Outcome and Assessment Information Set (OASIS, a group of standard data elements home health agencies (HHAs) integrate into their comprehensive assessment, to collect and report quality data to the Centers for Medicare & Medicaid Services (CMS)) data was transmitted within 30 days of completing the OASIS data sets. This failure created the risk of not reporting and coordinating patient care assessments timely for the patients receiving care and services at the HHA. Findings: During a review on 2/25/26 of the agency’s OASIS Validation reports dated January to February 2026, the following was identified: The agency’s “Oasis Agency Final Validation,” report dated 1/19/26 indicated, one of four data sets was submitted more than 30 days from the assessment completion date. The agency’s “Oasis Agency Final Validation,” report dated 2/11/26 at 2:57 PM indicated, three of eight data sets were submitted more than 30 days from the assessment completion date. The agency’s “Oasis Agency Final Validation,” report dated 2/11/26 at 3:09 PM indicated, one of one data sets was submitted more than 30 days from the assessment completion date. During a concurrent interview and record review on 2/25/26 at 12:39 PM with the Office Manager (OM), the Oasis Validation report dated 1/19/26 and the two Oasis Validation reports dated 2/11/26 were reviewed. The OM confirmed a total of 5 out of 13 data sets were submitted more than 30 days from the completion date for the submissions dated 1/19/26 and 2/11/26. The OM further stated that her work process had recently changed, and she now submitted the data sets every other week instead of weekly. The OM stated the data sets might have been submitted late because she became busy. During a review of the agency’s policy titled, “Condition of Participation: Reporting OASIS information 484.45,” dated 2/22/25, the policy indicated, “…An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system…within 30 days of completing the assessment of the beneficiary…””

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to review and identify all current medications for one of three sampled patients (Patient 1) when Patient 1’s currently used medications did not match Patient 1’s Plan of Care (POC - a doctor-certified, individualized document outlining specific skilled services, treatments, and goals for a patient’s recovery or maintenance at home). This failure had the potential to cause Patient 1 to suffer ineffective medication therapy, put Patient 1 at risk for medication errors, and experience side effects of medications without the HHAs knowledge. Findings: During a concurrent observation, interview and record review on 2/25/36 at 11 AM, during Patient 1’s home visit, Patient 1’s home medications were reviewed with Licensed Nurse (LN) 1. The following differences were noted when compared to Patient 1’s medications listed on the POC, dated 1/14/26: 1. Risperidone (used to treat behavioral disorders) 3 mg (milligrams -a unit of measure to equal 1/1000 of a gram) take 1 tab (tablet) by mouth every night at bedtime. -Patient 1’s POC dated 1/14/26, indicated: Risperidone 2 mg take 1 tab by mouth twice a day at 7 AM and 4 PM. 2. Eliquis (used to prevent the blood from clotting) 5 mg take 1 tab by mouth twice daily. -Patient 1’s POC dated 1/14/26, did not have the medication listed. 3. Pseudoephedrine (used to treat congested nose) 10 mg take 1 tab every 4-6 hours as needed for runny/stuff nose. -Patient 1’s POC dated 1/14/26 indicated: Pseudoephedrine HCl (hydrochloride (salts to make them dissolve better in water and blood, facilitating faster absorption)) 20 mg, 1 tab every 4 hours as needed, for stuffy/runny nose. In addition, the following discrepancies were found with Patient 1’s POC dated 1/14/26: -Ipratropium Inhaler (a prescription medication used to treat breathing difficulties by relaxing and opening air passages in the lungs through an inhaled mist) 0.02% 1 unit [one puff] as needed 4 times a day. The inhaler was not in the home or available for use to Patient 1; and, -Benadryl (a medication used for allergies) 25 mg, 1 Cap (capsule) as needed. The medication Benadryl was listed on Patient 1’s POC dated 1/14/26 but was missing the frequency (how often the medication should be taken). During an interview on 2/25/26 at 11:10 AM, LN 1 confirmed that Patient 1’s POC dated 1/14/26 did not have the updated or correct information compared to the medications Patient 1 was taking at home. LN 1 stated the expectation was that during each home visit the LN’s were supposed to confirm and compare the medications to the patient’s POC and verify with the patient’s care giver (PCG) if there were any medication changes since the last visit. LN 1 confirmed Patient 1 was visited three times a day, seven days a week. LN 1 stated that the medication changes and discrepancies should have been noticed and updated on Patient 1’s POC by her or another LN that visited Patient 1 previously that week. LN 1 further stated when they checked the medications they were expected to ensure the medication name, dosage, route, and frequency matched their POC. LN 1 explained it was important to verify the current medications so the LN could check for medication interactions, side effects, and it was best practice for patient safety. During an interview on 2/25/26 at 11:12 AM, with the PCG, the PCG confirmed that Patient 1 did not have an Ipratropium inhaler in the house. The PCG confirmed that Patient 1 had two medication changes, the dose of Risperidone and the new medication Eliquis was recently added. The PCG stated that when the LN’s came from the HHA they “sometimes” verified the medications, “but not often.” During an interview on 2/25/26 at 1:30 PM, with the Administrator (ADM) and the Clinical Nurse Supervisor (CNS), the ADM stated their expectation during every home visit was the LN would review and verify with the PCG or patient if there were any medication changes. The ADM further stated it was expected that the LN looked at everything related to the patient’s POC and document any changes. During a concurrent interview and record review on 2/25/26 at 2:07 PM with the ADM, Patient 1’s nursing visit records from the 3 visits on 2/23/26, two visits on 2/24/26, and the 7:21 AM visit on 2/25/26 were reviewed. The ADM confirmed that all of the documentation for the 6 visits had the box check marked, “No,” where the nursing visit record indicated, “…Medication change since last visit…” A review of the facility Policy and Procedure titled, “Medication Classification and Administration,” dated June 2003, indicated, “…A complete list of the patient’s medications, dosage, frequency, and route is maintained in the clinical record in the form of a medication profile. The profile is revised as often as necessary to reflect medication changes…Should discrepancies between what is ordered and what the patient is taking occur, the medication regime is verified with the physician…””