Excellence Home Health Care Agency 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 facility failed to ensure Patient 6’s discharge summary entered into the Outcome and Assessment Information Set (OASIS - a data collection system used by home health agencies (HHAs) to collect and report patient information) accurately reflected services the patient received by the HHA when the OASIS discharge summary incorrectly indicated Patient 6 received physical therapy services when in fact, he did not. This failure resulted in the facility’s transmission of incorrect information to be submitted into the Oasis system for Patient 6 which had the potential for inaccurate information to be used in the calculation of quality reports which are utilized to monitor quality of care, guide performance improvement, and determine reimbursement. During a review of Patient 6’s “Patient Profile,” (a document which provides medical and demographic information), undated, indicated Patient 1 had a start of care date of November 7, 2024, and diagnoses which included malignant neoplasm of central portion of right female breast (breast cancer), type 2 diabetes mellitus (disease characterized by persistently high blood sugar levels) and muscle weakness. During a review of Patient 6’s OASIS discharge summary, dated January 5, 2025, the summary indicated, “…Care summary: (care given, progress, regress including therapies)…services provided: skilled nursing, PT [physical therapy]…” However, during further review of Patient 6’s Electronic Medical Record (EMR), there was no evidence that physical therapy services were provided to Patient 6. During a concurrent interview and record review on February 27, 2025, at 2:10 PM, with the Assistant Administrator (ASST ADMIN), Patient 6’s OASIS discharge summary, dated January 5, 2025, was reviewed. The ASST ADMIN acknowledged the OASIS discharge summary indicated Patient 6 received physical therapy services. Patient 6’s EMR was also reviewed and the ASST ADMIN stated the OASIS discharge summary, dated January 5, 2025, was incorrect and Patient 6 did not receive physical therapy services. The ASST ADMIN further stated it was his expectation that information transmitted through the OASIS system was supposed to be accurate and correct. During a review of the facility’s policy and procedure titled, “Oasis Data Transmission,” revised November 2021, the policy indicated, “Purpose – To outline the OASIS data transmission requirements…Policy – The organization will adhere to all OASIS data transmission requirements as outlined in the Medicare Conditions of Participation, Reporting of OASIS information 42 CFR 484.45…2. The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. 3. The organization must electronically transmit accurate, complete and encoded OASIS data for each patient…” During a review of the facility’s policy and procedure titled, “Entries Into the Clinical Record,” revised November 2021, the policy indicated, “…Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided…the medical record should accurately reflect a clear account of the patient’s entire course of care…3. Entries into the clinical record will be clear, concise, and specific statements of fact…””

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on interview and record review, the facility failed to ensure background checks were performed on three of six sampled staff upon hire Registered Nurse 1 [RN 1], Assistant Administrator [ASST ADMIN] and Physical Therapist 1 [PT 1]). This failure resulted in the facility hiring of staff members without first ensuring their background was clear of criminal history related to abuse, neglect, or mistreatment and had the potential to result in mistreatment of patients by the staff members. During a review of RN 1’s employee file, RN 1’s hire date was listed as October 26, 2009. Further review of RN 1’s employee file indicated there was no documented evidence the facility had performed a background check for RN 1 when initially hired. During a review of the ASST ADMIN employee file, the ASST ADMIN’s hire date was listed as November 23, 2009. Further review of the ASST ADMIN employee file indicated there was no documented evidence the facility had performed a background check for the ASST ADMIN when initially hired. During a review of PT 1’s employee file, PT 1’s hire date was listed as March 26, 2007. Further review of PT 1’s employee file indicated there was no documented evidence the facility had performed a background check for PT 1 when initially hired. During an interview on February 27, 2025, at 2:13 PM, with the ASST ADMIN, the ASST ADMIN stated he was unable to find background checks done upon hire for RN 1, ASST ADMIN, or PT 1. The ASST ADMIN further stated the facility was doing background checks on staff at the time the staff were hired but he could not find documented evidence that they were completed upon hire. During a review of the facility’s policy and procedure titled, “Selection/Hiring of Personnel,” revised November 2021, the policy indicated, “Purpose – To specify the criteria for the recruitment and hiring of staff to meet the care needs of appropriate patients…2. A criminal background check will be obtained for positions required by law, regulation, or organizational policy…””

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interview and record review, the facility failed to ensure Electronic Medical Records (EMR) for one of seven sampled patients (Patient 4) was accurate when an occupational therapy assessment (an assessment of an individuals in terms of their specific physical or mental difficulties, to determine how they are functioning at home and what therapy is needed to enable them to perform daily activities) and physicians orders for another patient were entered into Patient 4’s EMR in error. This failure resulted in Patient 4’s medical records to inaccurately reflect Patient 4’s health status and include physicians orders not intended for the patient which had the potential for Patient 4 to receive care and services not in accordance with the patients actual plan of care. During a review of Patient 4’s “Patient Profile,” (a document which provides medical and demographic information), undated, indicated Patient 1 had a start of care date of January 18, 2025, and diagnoses which included pressure ulcer of left buttocks stage 3 (a localized area of skin and/or underlying tissue damage caused by prolonged pressure on the skin), and type 2 diabetes mellitus (disease characterized by persistently high blood sugar levels) with diabetic nephropathy (damage to the kidneys due to diabetes). During a review of Patient 4’s EMR, there was a document titled “OT [occupational therapy] Evaluation and Physician’s Order” dated February 6, 2025, which indicated an occupational therapy evaluation was performed and OT services were needed to meet long term and short term goals. During a concurrent interview and record review on February 24, 2025, at 1:45 PM, with Office Assistant 1 (OF 1), OF 1 reviewed Patient 4’s Electronic Medical Record and acknowledged there was an occupational therapy assessment and occupational therapy physician’s order, dated February 6, 2025, in Patient 4’s medical record. Upon further review of the “OT Evaluation and Physician’s Order” in Patient 4’s medical record, OF 1 stated he made an error and mistakenly took the occupational assessment and physician’s orders for another patient and input them into Patient 4’s Electronic Medical Record. OF 1 further stated he got confused because the resident’s last names were identical. OF 1 acknowledged the error had not previously been identified. During an interview on February 24, 2025, at 2:00 PM, with the Administrator (ADMIN), the ADMIN stated OF 1 mistakenly entered physician’s orders and occupational therapy information into the wrong patient’s electronic medical record. The ADMIN further stated Patient 4, never had physician’s orders for occupational therapy services. During an interview on February 27, 2025, at 2:00 PM, with the Assistant Administrator (ASST ADMIN), the ASST ADMIN stated the facility expectation was that all patients’ electronic medical records were to be maintained with accurate and correct information. During a review of the facility’s policy and procedure titled, “Entries Into the Clinical Record,” revised November 2021, the policy indicated, “…Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided…the medical record should accurately reflect a clear account of the patient’s entire course of care…3. Entries into the clinical record will be clear, concise, and specific statements of fact…””