On Going Home Health Care Limited

“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 Center for Medicaid and Medicare Services (CMS) Outcome and Assessment Information Set (OASIS) Error detail report revealed the agency failed to electronically transmit each completed OASIS assessment to the CMS system, regarding each patient with respect to the which information is required, within 30 days of the completing the assessment of the patients in 1 of 2 patients who received insulin administration records reviewed (Patient #21). Findings include: 1. Review of the OASIS Error detail report from 5/1/25 to 5/1/26 revealed 108 assessments which pertained to multiple 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 5/1/25 to 5/1/26 revealed Patient #21 had an OASIS recertification completed on 3/1/26. The OASIS recertification was not submitted until 4/28/26 or 28 days after the 30 day submission deadline date. Review of Patient #21’s medical record revealed an OASIS recertification assessment which did have a “M0090” date of 3/1/26. During an interview on 5/21/26 at 2:38 p.m., the Administrator Director of Nursing (DON) and owner #1 and owner #2, stated the agency had been aware about issues regarding the OASIS since 2024. The Administrator DON and both owners stated they were working with their consultant on this problem but did admit the agency was not doing on transmitting the OASIS within the 30 day window.”

“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 interview and record review, the agency failed to ensure the Outcome and Assessment Information Set (OASIS) data accurately reflected the patient’s status at the time of assessment in 6 of 21 patient records reviewed (Patient #2, #4, #6, #14, #17 and #20). Findings include: 1. The clinical record for Patient #17 was reviewed on 5/15/26. The plan of care (POC) for the certification period dated 4/11/26 to 6/9/26 revealed a start of care date of 12/12/25; diagnoses included attention-deficit hyperactivity disorder, anxiety disorder, bipolar disorder, nicotine dependence and personal history of mental and behavioral disorders. POC orders included skilled nursing visits twice a day for 60 days for medication management and medication administration. a. The agency failed to ensure Patient #17’s OASIS recertification assessment had accurate information. A review of Patient #17 POC dated 4/11/26 revealed the home address of the patient. However during a home visit on 5/20/26 Patient #17 was observed to be living at a different address than what was written on the POC. A review of Patient #17 OASIS recertification assessment dated 4/10/26 revealed the same address as was listed on the POC, which as previously mentioned was not the address Patient #17 resided at. During an home visit interview to the home of Patient #17 on 5/20/26 at 6:30 a.m., the patient stated she had lived at the current location for four months. Review of the clinical record for Patient #17 revealed a patient profile which was printed on 5/14/26 by the state surveyors. The address listed on the patient profile for Patient #17 matched the address listed on the POC dated 4/11/26 and the OASIS recertification assessment. Per the interview with Patient #17, the patient had not lived at the location listed on the POC, OASIS reassessment and the patient profile for at least four months. 2. Similar findings concerning wrong addresses were found on the OASIS recertification of Patient #2, #4, #6, #14 and #20. 3. During an interview on 5/21/26 at 2:38 p.m., the Administrator Director of Nursing (DON) and owner #1 and owner #2 stated the address in the OASIS was autopopulated from the information in the agency’s electronic medical record (EMR) system. The administrator DON and owners also stated the agency had failed to update the address of all of the above patients, which is why the information listed on the OASIS recertification assessment was incorrect. The administrator, DON and owners agreed the correct address was an important information to have the accurate information off.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on observation record review and interview, the agency failed to alert the physician to a change in the patient’s condition after a change was observed, which suggested the plan of care may need to be altered for 1/1 patients reviewed with a change in condition (Patient #20). Findings include: 1. Record review completed on 5/14/26 at 3:22 p.m. revealed a plan of care (POC) for Patient #20 with a certification period of 5/11/26 to 9/9/26. Review of the plan of care completed on 5/20/26 revealed no documentation of the DME (cane) or any other assistive device. Diagnoses included on the plan of care include a primary diagnosis of bipolar disorder, and secondary diagnoses of low back pain, chronic pain, pain in the right and left hip, as well as pain in the left arm. a. The agency failed to notify the physician of a potential change in the patient’s condition or the need to alter the plan of care after a change in the use of durable medical equipment (DME) was observed. During a home visit conducted on 5/20/26 at 6:30 a.m., Consumer #20 was observed utilizing a cane while ambulating within the home. During the home visit, when surveyors questioned the registered nurse (RN #4), she stated she had never previously observed the consumer using a cane. She further stated to surveyors Consumer #20 suffered from chronic pain. Consumer #20 supported this, stating they had difficulty with ambulation. During a follow-up interview conducted on 5/21/26 at 2:45 p.m., RN #4 stated she had been seeing Consumer #20 for approximately two to three months and confirmed the consumer did not normally use a cane. RN #4 further stated the consumer “walks fine” and acknowledged the cane was not listed in the consumer’s DME. When questioned if the RN notified the physician of the use of the cane and a change in DME, RN #4 stated she had not contacted the physician. The agency owner (Employee #2), during the interview, stated RN #4 should have contacted the doctor and explained the expectation is for care coordination to occur in situations such as this. The agency owner acknowledged that the agency failed to follow their own expectations, as well as regulatory standards, and would work towards improving this in the future.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on the interview and record review, the agency failed to ensure ongoing interdisciplinary assessment occurred to re-evaluate the medical needs for 1 of 1 patients reviewed with duplicated documentation (Patient#4). Findings include: 1. The clinical record for Patient #4 was reviewed on 5/12/26. The Plan of Care for the certification period dated 4/2/26 to 5/31/26 revealed a start of care date of 6/6/25; diagnoses included psychoactive substance abuse and myalgia. Plan of Care orders included skilled nursing once a day for 60 days for medication management and administration, disease management, and compliance and safety at home. a) The agency failed to appropriately reassess the status, needs, and overall well-being of patients under their care when the patients were receiving skilled nursing care for medication administration and pain assessment. Review of visit notes for Patient #4 showed that the patient had four different nurses from 5/1/26 to 5/11/26. Licensed Practical Nurse (LPN ) #8 saw the patient on 5/1/26 and 5/3/26. Registered Nurse (RN) #9 saw the patient on 5/2/26. LPN #7 saw the patient on 5/4/26, 5/5/26, 5/6/26, 5/7/26, 5/8/26, 5/9/26, 5/10/26, and 5/11/26. RN #6 saw the patient on 5/5/26. Further record review showed that the visit narrative and intervention documentation from 5/1/26 through 5/11/26 were documented exactly the same across all clinicians. During an interview on 5/14/26 at 3:16 p.m., the Administrator Director of Nursing (DON) and owners #1 and #2 stated the agency had been aware of the copying and pasting of the visit narratives and interventions, and the agency was working on efforts to improve this non-compliance. They stated that they have completed training to address the expectations for visit documentation; however, they noted it is difficult to review all clinical documentation. When questioned regarding whether they had a performance improvement plan, they stated they did not, and had only provided the education once on the matter They stated that they plan on doing more training more frequently to address the problem and would address it further in the future.”