Phoebe 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 staff interview and Centers for Medicaid and Medicare Services (CMS) report, the agency failed to submit to CMS a completed Outcome and Assessment Information Set (OASIS) within 30 days of completing the assessments. Findings include: On 5/1/2024 at 10:45 a.m., an interview with the Administrator confirmed awareness of OASIS submission timeframe requirements. Review of CMS report titled “HHA Error Summary by Agency 117100”, revealed the following: GA117100, PHOEBE HOME HEALTH, Albany, Ga, -3330 (Error Number), Record Submitted Late: The submission date is more than 30 days after MOO90 on this new record.”

“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, policy review, and staff interview, it was determined that the agency failed to ensure that the plan of care included all required elements to address safety measures to protect against injury for two patients (P) (P#1 and P#11) of 17 sampled patients. Findings include: Review of the policy titled “Care Planning Process” review date 8/21/23 reveals the following: The plan of care will include (but not limited to): a. Identified patient/client problems and needs b. specific services by provided c. Reasonable, measurable and individualized goals d. actions to be taken to meet those goals e. type, frequency and duration of above actions f. equipment and supplies g. Prognosis h. Precautions, instructions, activities permitted, safety measures 1. P#1 was admitted to home health on 3/21/24 with a pertinent diagnosis of end stage renal disease and dependence on renal dialysis (a condition where the kidney reaches advanced state of loss of function) and requires dialysis treatment through arteriovenous (AV) access (a surgical procedure that creates a direct connection between an artery and a vein) three times a week. Review of the plan of care failed to reveal documentation of the presence of the AV shunt (hole or small passage that moves or allows movement of fluid from one part of the body to another) or interventions to protect the patient’s AV shunt from harm, such as to avoid blood pressures or venipunctures in this extremity. 2. P#11 was admitted to home health on 4/9/24 with a pertinent diagnosis of end stage renal disease and dependence on renal dialysis (a condition where the kidney reaches advanced state of loss of function) and requires dialysis treatment through AV access three times a week. Review of the plan of care revealed documentation of the presence of a fistula (an artificial connection made between an artery and vein for dialysis access) however, the plan of care failed to specify the location of the fistula or interventions to protect the patient’s fistula from harm, such as to avoidance of blood pressures or venipunctures in this extremity. The agency failed to ensure that the plan of care included safety precautions to protect safety of the patient and preserve the AV shunt. During an office interview on 4/30/24 at approximately 10:00 a.m. with the Clinical Informatics Educator, it was confirmed the agency staff failed to include safety precautions on the plan of care to ensure the safety of the patient’s AV shunt.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on clinical record reviews, policy review, and staff interview, it was determined that the agency staff failed to ensure verbal orders were signed and dated by the physician in accordance with the home health agency’s policies for three of seventeen sampled patients (P) (P#2, P#4 and P#6). Findings were: Review of the agency policy titled, “Physician Orders/ Plan of care” review date 8/21/23 reveals the following: 4. All diagnostic and therapeutic orders, including verbal orders, will be signed by the physician, and incorporated into the clinical record within thirty days. 1. Review of the plan of care for P#2 with a recertification period of 3/9/24 - 5/7/24 revealed the plan of care failed to be approved and signed by the physician as of 4/30/24. The agency failed to ensure the plan of care which contains verbal orders was signed and dated by the physician within 30 days. 2. Review of the plan of care for P#4 with a recertification period of 2/10/24 - 4/9/24 revealed the plan of care failed to be approved and signed by the physician as of 4/30/24. The agency failed to ensure the plan of care which contains verbal orders was signed and dated by the physician within 30 days. 3. Review of the plan of care for P#6 with a recertification period of 2/18/24 - 4/17/24 revealed the plan of care failed to be approved and signed by the physician until 3/20/24. The agency failed to ensure the plan of care which contains verbal orders was signed and dated by the physician within 30 days. During an in-office interview on 4/30/24 at approximately 11:00 a.m. with the Clinical Informatics Educator, a request was made for the signed copy of the plan of care for P#2, P#4, and P#6. Clinical Informatics Educator revealed the plan of care had not yet been signed by the physician or within the 30-day timeframe.”