At Home Healthcare

“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, of the CMS OASIS Error Detail report, the agency failed to electronically transmit current and accurate data regarding each beneficiary with respect to which information was required to be transmitted within 30 days of completing the assessment of the beneficiary for 2 of 2 focus sample records reviewed (Focus Sample A and B) whose data was transmitted from 1/1/25 through 1/1/26. Findings include: 1. Review of the OASIS Error detail report from 1/1/25 through 1/1/26 revealed seven assessments which pertained to seven different patients, which were submitted more than 30 days after the “M0090” date which was the last date information used to complete the comprehensive assessment and determine the OASIS coding gathered by the assessing clinician. a. The agency failed to ensure OASIS data was transmitted within 30 days of completing the assessment. Review of the OASIS error report for 1/1/25 to 1/1/26 revealed Focused Sample A had an OASIS recertification completed on 11/5/25. The OASIS recertification was not submitted until 12/10/25 or five days after the 30 day submission deadline date. On 1/7/25 a review of the agency’s electronic medical record (EMR) system revealed the agency had started the OASIS on 11/5/25. It was locked on 11/20/25 and sent on 12/9/25. 2. Similar findings were found for Focused Sample B. 3. During an interview on 1/6/25 at 8:22 a.m., the administrator stated the issues with the OASIS reports being transmitted late was an internal issue with the agency’s quality process. The administrator stated an office quality process was holding the transmission of the completed OASIS past its due date and she was not aware of this new process. During an interview on 1/8/25 at 3:45 p.m., the administrator again stated the quality process was backed up and she was not aware of this new process. The administrator stated she was aware of this process and would fix it going forward.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on record review and interview, the agency failed to coordinate care delivery to meet the patient’s needs for 1 of 4 patient records reviewed who were receiving skilled nursing services related to wound care (Patient #6). Findings include: 1. The clinical record for Patient #6 was reviewed on 01/06/2026. The plan of care with certification period of 11/12/25 to 1/10/26 revealed a start care date of 11/12/25. Patient #6 had the following diagnoses; type 2 diabetes mellitus with hyperglycemia and cataract, chronic obstructive pulmonary disease, age-related osteoporosis and pressure ulcers on both heels. Plan of care orders include skilled nursing (SN) visits once a week for one week, five times a week for 4 weeks, and two as needed visits for wound care. Additionally an updated order was sent on 12/22/25 for an additional five times a week SN visits for wound care for an unspecified number of weeks. a. The agency failed to coordinate care delivery to meet Patient #6’s needs, specifically the agency failed to inform the physician of cancelled or missed visits. Records review for Patient #6 done on 1/6/26 revealed 3 missed visits from 11/12/25 to 1/6/26 with no documentation of the reasons for the missed visits and notification of the physician of these missed visits. There was no further documentation as to why these visits were missed or as to why the physician was not notified of the missed visits. During an interview on 1/7/26 at 9:17 a.m., the administrator stated Patient #6 did not want to be seen on holidays. During an interview on 1/8/26 at 8:57 a.m., the licensed practical nurse (LPN), who provided care to Patient #6, stated the patient refused holiday visits. During an interview on 1/8/26 at 8:59 a.m., the administrator stated due to Patient #6 reporting not wanting visits on holiday, she had not documented and reported the missed visit to the physician.”