Crescent Home Health

“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 titled “OASIS Capture, Transmission, Verification, Display and Reports,” 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 CMS report titled “HHA Error Summary by Agency,” with report period of 02/01/2024 - 02/01/2025 and run date of 2/17/2025, revealed the agency failed to transmit OASIS data to CMS system within 30 days. Review of the policy titled “OASIS Data Capture, Transmission, Verification, Display and Report” last revised 03/01/21, revealed the following: 2. Transmittal of OASIS data a. At least monthly, Agency will electronically transmit accurate, completed, encoded and locked OASIS data to the state agency. All OASIS assessments completed must be transmitted within thirty (30) days of M0090 date. During an in-office interview on 3/26/2025 at 10:00 am, the Executive Director (ED) revealed that she was aware that the 30-day OASIS submission timeframe requirements were not met during the time frame of 02/01/2024 - 02/01/2024 and that the agency has experienced issues with nursing staff submitting OASIS reports on time. The ED stated the agency has submitted the late submission concerns in their Quality Assurance meeting for discussion and a plan of correction has been started.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record reviews, observation, staff and patient interviews, and policy titled “Plan of Care (POC).” it was determined that the agency failed to obtain a physician order for an indwelling catheter (a flexible tube placed in the bladder for drainage) for one patient (P) (P#4) of 17 patients sampled. Findings include: Review of policy titled “Plan of Care (POC),” Policy Number: 2.1.007, revised date: 09/01/24, revealed the following: Policy: Each patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient’s problems, needs, and goals, as well as to address specific services being provided. PROCEDURE: 2. The POC includes: n. all patient care orders During a home visit observation with P#4 on 3/25/25 at 10:00 a.m., observed a urinary catheter with tubing draining urine attached to P#4’s walker. The occupational therapist (OT) OT CC did not address the catheter. The OT CC instructed P#4 to be careful with the urinary catheter tubing as not to dislodge it. In an interview on 3/25/25 at 10:30 a.m., P#4 stated that the catheter was placed on 3/18/25 by the urologist. P#4 stated that she was unable to urinate. In an interview on 3/25/25 at 10:50 a.m., OT CC confirmed that the P#4 is wearing a catheter, but she is not aware that nurse did not obtain physician order for indwelling catheter. OT CC confirmed that the physicians order was not included on the care plan. During an interview on 3/25/25 at 2:45 p.m., the Administrator confirmed there was no physician order for an indwelling catheter for P#4.”

“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 record reviews, staff interviews, and policy titled “Plan of Care (POC),” it was determined the agency failed to include goals, and interventions with primary diagnosis and comorbidity for three patients (P) (P#2, P#7, P#8), of 17 sampled patients. The findings include: Review of the policy titled “Plan of Care (POC),” Policy Number: 2.1.007, revised 09/01/24, reveals the following: Policy: “Each patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient’s problems, needs, and goals, as well as to address specific services being provided.” PROCEDURE: 2. The POC includes: h. Pertinent diagnosis (es). i. Patient specific interventions and education; measurable outcomes and goals identified by the agency and patient. 1. Review of the plan of care (POC) for P#2 (certification period (start of care) of 3/4/2025 to 5/2/2025) revealed P#2 was admitted to the Home Health agency on 11/4/2024, with a diagnosis of end stage renal disease (a condition where the kidney reaches advanced state of loss of function). The agency failed to address goals, and interventions on the POC to assess and monitor the fistula (connection that a surgeon makes between an artery and a vein to make it possible for patient to receive hemodialysis) on left upper arm site for dialysis for bleeding and signs of infection. 2. Review of the POC for P#7 (certification period (start of care) of 2/18/2025 to 4/18/2025) revealed P#7 was admitted to the Home Health agency on 2/18/2025, with a diagnosis of congestive heart failure (a medical condition where the heart muscle is unable to pump blood effectively, leading to fluid buildup in the body). The agency failed to address goals, and interventions, on the POC to assess and monitor the weight or parameter to measures the calf for edema. 3. Review of the POC for P#8 (certification period (start of care) of 1/6/2025 to 3/6/2025) revealed P#8 was admitted to the Home Health agency on 1/6/2025, with a diagnosis of type 2 diabetes (a medical condition in which your body cannot use insulin correctly and sugar builds up in the blood). The agency failed to address goals, and interventions, on the POC to obtain physician’s order to monitor blood glucose. During a telephone interview with Registered Nurse (RN) AA on 3/25/2025 at 1:15 p.m., RN AA confirmed that the intervention on diagnosis of end stage renal disease on P#2’s POC was not addressed because she was not aware that she had to obtain order to assess and monitor for bleeding and infection at fistula site. During an interview on phone with RN BB on 3/25/2025 at 2:40 p.m., RN BB confirmed that the agency failed to address intervention on diagnosis of end stage renal disease on P#2 POC, because she was not aware that she had to include it (intervention). On 3/25/2025 at 4:15 p.m., an interview conducted with the Administrator, who acknowledged that she failed to correct or include intervention for the diagnosis of end stage renal disease for P#2, congestive heart failure for P#7, and Type 2 diabetes for P#8.”