Atrium Health Navicent at Home

“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 the Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report, policy “OASIS Assessments,” and staff interview, it was determined that the agency failed to electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the CMS system every 30 days. Findings include: Review of the policy titled “OASIS Assessments” last revised 07/05/2024, revealed the following: Encoding and Transmission: As the OASIS and PPS systems evolves, the requirements for encoding and transmission are subject to change, so CGHH will be guided by the appropriate HCFA regulations in this area. Review of CMS report titled “HHA Error Summary by Agency,” with report period of 01/01/2024-12/31/2024 and run date of 2/3/2025, revealed the agency failed to transmit OASIS data to CMS system within 30 days. During an in-office interview on 2/18/2025 at 3:20 pm, the Director explained that she was unaware that the 30-day OASIS submission timeframe requirements were not met during the time frame of 01/01/2024 through 12/31/2024.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on review of the policy titled “Plan of Care and Provider Orders”, record reviews, staff and patient interview, it was determined the agency failed to ensure that the individualized plan of care includes all medications and treatments related to the patient’s diagnoses for two patients (P) (P #9, P #16) of 17 sampled patients. Findings include: Review of the policy titled, “Plan of Care and Provider Orders”, Policy Number PC 014, effective date 10/15/2024, reveals the following: Policy Services will be provided in accordance with the Plan of Care, signed by an approved provider, and based on the patient’s diagnosis and assessment of immediate and long-range needs and patient/community resources. Home Health 1. The Plan of Care includes: • Pertinent Diagnoses. • All medications and treatments 1. Record review reveals P#9 was admitted on 1/27/2025 with the diagnosis of femur (thigh bone) fracture and co-morbidities that include atrial fibrillation (a medical condition where the upper chambers of the heart beat irregularly and rapidly, causing an abnormal heart rhythm). Review of “Home Health Certification and Plan of Care”, dated 1/27/2025, reveals P#9 was prescribed Warfarin (a blood thinning medication used to treat and prevent blood clots). Further review of the clinical record failed to reveal interventions related to bleeding precautions or ongoing monitoring of Warfarin. An interview on 2/18/2025 at approximately 10:30 a.m. was conducted during a home visit with P#9, who confirmed taking Warfarin. The patient revealed that he is followed monthly by his physician for lab work to manage the Warfarin. 2. Record review reveals P#16 was admitted on 9/25/2025 with a diagnosis of Type 2 Diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) with foot ulcer. Review of “Home Health Certification and Plan of Care”, dated 1/22/2025, reveals P#16 has an insulin pump (a small, portable device that delivers insulin continuously or in bolus doses to people with diabetes). Further review of the clinical record failed to reveal insulin dosage or interventions related to the care and maintenance of the insulin pump. An interview on 2/19/2025 at approximately 10:00 a.m. was conducted at the agency with the Director, who confirmed the plan of care was incomplete for both patients.”