Medside Home Health Agency

“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,” 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,” revealed the following: Procedure: After clinical staff assesses a patient and data entry of OASIS questions have been completed, the information entered into the database must be locked. The OASIS file should be automatically generated by the system and submitted within 3 business days. Review of CMS report titled “HHA Error Summary by Agency,” with report period of 04/01/2024-04/01/2025 and run date of 04/22/2025, revealed the agency failed to transmit OASIS data to CMS system within 30 days. During an in-office interview on 05/06/2025 at 12:06 pm, the Administrator revealed that he was unaware that the 30-day OASIS submission timeframe requirements were not met during the time frame of 04/01/2024 through 04/01/2025.”

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on home visit observations, patient and staff interviews, it was determined that the agency failed to ensure that written information and instruction was provided to the patient outlining care and services for three home visit patients (P) (P#13, P#14, and P#16) of five sampled home visit patients. Findings include: 1. During a home visit observation on 5/5/25 at approximately 2:00 p.m., for P#13, the home health admissions packet was reviewed however, the packet failed to include written instructions and information regarding planned visit schedule and frequency, medication schedule and instructions, and care and treatments the agency will provide to the patient. During an in-home interview with P#13 on 5/5/25 at 2:20 p.m., P#13 confirmed that she did not have written information regarding visit schedules, medication schedules and care plan instructions but was able to go online and get that information if she needed to. During an interview with the physical therapist (PT) (MM) on 5/5/25 at 2:30 p.m., PT MM confirmed that he does not provide written instructions/ written visit schedules or plan of care to the patient, and he calls the night before the visit to confirm the visit for the next day. 2. During a home visit observation on 5/6/25 at approximately 9:00 a.m., for P#14 the home health admissions packet was unable to be located. During an interview with P#14 on 5/6/25 at 9:20 a.m., P#14 reported that he does not know where his admissions packet is. It was confirmed that he did not have a visit schedule. During an interview with the Registered Nurse (RN) (LL) on 5/5/25 at 9:30 a.m., RN LL confirmed that he does not provide written instructions/ visit schedules to the patient, and he calls the night before the visit to confirm the visit for the next day. 3. During a home visit observation on 5/5/25 at approximately 3:30 p.m., for P#16, the home health admissions packet was reviewed. However, the packet failed to include written instructions, information regarding planned visit schedule, medication schedule and instructions, and care and treatments the agency will provide. During an in-home interview with P#16 on 5/5/25 at 4:00 p.m., P#16 confirmed that he did not have written information regarding visit schedules, medication schedules and care plan instructions and does not have access to a computer to retrieve that information if needed. During an interview with the physical therapist (PT) (KK) on 5/5/25 at 4:10 p.m., PT KK confirmed that he does not provide written instructions/ written visit schedules to the patient, and he calls the night before the visit to confirm the visit for the next day. During an office interview on 5/7/25 at approximately 10:00 a.m., the Administrator confirmed that the agency does not provide any written instructions to include visit schedule, medication schedule and instructions, and care and treatments the agency will provide. He also stated that at start of care, the staff ask the patients if they want the information and if they say they want the information the agency will provide the information but if the patient declines the information then the agency will not provide the information.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on record reviews, staff interview, and policy titled “Discharge/Transfer/ Referral of Patients,” it was determined that the agency failed to ensure that a comprehensive discharge summary was completed at discharge to assist in the continuity of care post discharge for five patients (P) (P#1, P#2, P#3, P#4, and P#5) of five sampled discharge patients. Findings include: Review of policy titled “Discharge/Transfer/ Referral of Patients,” Effective date: 2005, revealed the following: Procedure • The discharge summary becomes part of the patient’s home care record within five (5) days of the discharge. 1. Review of the document titled “Home Health Certification and Plan of Care” for P#1 revealed that P#1 was admitted to services on 1/1/2025 and was discharged from agency on 3/2/2025. 2. Review of the document titled “Home Health Certification and Plan of Care” for P#2 revealed that P#2 was admitted to services on 9/23/2024 and was discharged from agency on 11/21/2024. 3. Review of the document titled “Home Health Certification and Plan of Care” for P#3 revealed that P#3 was admitted to services on 1/28/2025 and was discharged from the agency on 11/13/2024. 4. Review of the document titled “Home Health Certification and Plan of Care” for P#4 revealed that P#4 was admitted to services on 11/16/2024 and was discharged from the agency on 1/8/2025. 5. Review of the document titled “Home Health Certification and Plan of Care” for P#5 revealed that P#5 was admitted to services on 6/7/2024 and was discharged from the agency on 1/8/2025. Review of the clinical record for P#1, P#2, P#3, P#4, and P#5 failed to include a discharge summary. During an office interview on 5/6/2025 at 2:30 p.m., with the Chief Executive Officer (CEO)/Medical Doctor revealed the CEO/Medical Doctor confirmed the discharge summary was not completed at discharge and was unable to provide a comprehensive discharge summary for P#1, P#2, P#3, P#4, and P#5.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on home visit observations, patient and staff interviews, it was determined that the agency failed to ensure that written information and instruction was provided to the patient outlining care and services for three home visit patients (P) (P#13, P#14, and P#16) of five sampled home visit patients. Specifically, the agency failed to provide a written visit schedule including frequency of visits to be made by staff. Findings include: 1. During a home visit observation on 5/5/25 at approximately 2:00 p.m., for P#13 the home health admissions packet was reviewed. However, the packet failed to include written instructions and information regarding planned visit schedule including frequency of visits. During an in-home interview with P#13 on 5/5/25 at 2:20 p.m., P#13 confirmed that she did not have written information regarding visit schedules and frequency but was able to go online and get that information if she needed to. During an interview with the physical therapist (PT) (MM) on 5/5/25 at 2:30 p.m., PT MM confirmed that he does not provide written visit schedules to the patient, and he calls the night before the visit to confirm the visit for the next day. 2. During a home visit observation on 5/6/25 at approximately 9:00 a.m., for P#14 the home health admissions packet was unable to be located. During an interview with P#14 on 5/6/25 at 9:20 a.m., P#14 reported that he does not know where his admissions packet is. It was confirmed that he did not have a visit schedule. During an interview with the registered nurse (RN) (LL) on 5/5/25 at 9:30 a.m., RN LL confirmed that he does not provide written instructions/ visit schedules to the patient, and he calls the night before the visit to confirm the visit for the next day. 3. During a home visit observation on 5/5/25 at approximately 3:30 p.m., for P#16 the home health admissions packet was reviewed. However, the packet failed to include written instructions and information regarding planned visit schedule to include frequency. During an in-home interview with P#16 on 5/5/25 at 4:00 p.m., P#16 confirmed that he did not have written information regarding visit schedules and did not have access to a computer to retrieve this information. During an interview with the physical therapist (PT) (KK) on 5/5/25 at 4:10 p.m., PT KK confirmed that he does not provide written visit schedules to the patient, and he calls the night before the visit to confirm the visit for the next day. During an office interview on 5/7/25 at approximately 10:00 am, the Administrator confirmed that the agency does not provide any written instructions to include visit schedule, medication schedule and instructions, and care and treatments the agency will provide. He also stated that upon admission, the staff ask the patients if they want the information and if they say they want the information the agency will provide the information but if the patient declines the information then the agency will not provide the information.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on home visit observations, patient and staff interviews, it was determined that the agency failed to ensure that written information and instruction was provided to the patient outlining care and services for three home visit patients (P) (P#13, P#14, and P#16) of five sampled home visit patients. Specifically, the agency failed to provide medication schedule and instructions to the patient as required. Findings include: 1. During a home visit observation on 5/5/25 at approximately 2:00 p.m., for P#13, the home health admissions packet was reviewed. However, the packet failed to include the written instructions and information regarding medication schedule and instructions. During an in-home interview with P#13 on 5/5/25 at 2:20 p.m., P#13 confirmed that she did not have written information regarding medication schedules but was able to go online and get that information if she needed to. During an interview with the physical therapist (PT) (MM) on 5/5/25 at 2:30 p.m., PT MM confirmed that he does not provide written instruction regarding medications to the patient. 2. During a home visit observation on 5/6/25 at approximately 9:00 a.m., for P#14 the home health admissions packet was unable to be located. During an interview with P#14 on 5/6/25 at 9:20 a.m., P#14 reported that he does not know where his admissions packet is. It was confirmed that he did not have a medication list provided by the agency. During an interview with the registered nurse (RN) (LL) on 5/5/25 at 9:30 a.m., RN LL confirmed that he does not provide written instructions regarding medications instructions to the patient. 3. During a home visit observation on 5/5/25 at approximately 3:30 p.m., for P#16, the home health admissions packet was reviewed. However, the packet failed to include written instructions and information regarding medication schedule and instructions. During an in-home interview with P#16 on 5/5/25 at 4:00 p.m., P#16 confirmed that he did not have written information regarding medication schedules from the agency. During an interview with the physical therapist (PT) (KK) on 5/5/25 at 4:10 p.m., PT KK confirmed that he does not provide written instructions regarding medication instructions to the patient. During an office interview on 5/7/25 at approximately 10:00 a.m., the Administrator confirmed that the agency does not provide any written instructions to include visit schedule, medication schedule and instructions, and care and treatments the agency will provide. He also stated that upon admission, the staff ask the patients if they want the information and if they say they want the information the agency will provide the information but if the patient declines the information, then the agency will not provide the information.”

“Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This Element is not met as evidenced by: Based on home visit observations, and patient and staff interviews, it was determined that the agency failed to ensure that written information and instruction was provided to the patient outlining care and services for three home visit patients (P) (P#13, P#14, and P#16) of five sampled home visit patients. Specifically, the agency failed to provide information of any treatments to be administered by the staff. Findings include: 1. During a home visit observation on 5/5/25 at approximately 2:00 p.m., for P#13, the home health admissions packet was reviewed. However, the packet failed to include written instructions and information regarding care and treatments the agency will provide. During an in-home interview with P#13 on 5/5/25 at 2:20 p.m., P#13 confirmed that she did not have written information regarding a plan of care but was able to go online and get that information if she needed to. During an interview with the physical therapist (PT) (MM) on 5/5/25 at 2:30 p.m., PT MM confirmed that he does not provide a plan of care to outline how care and services will be provided to the patient. 2. During a home visit observation on 5/6/25 at approximately 9:00 a.m., for P#14, the home health admissions packet was unable to be located. During an interview with P#14 on 5/6/25 at 9:20 a.m., P#14 reported that he does not know where his admissions packet is and does not have a plan of care to outline care and services being provided. During an interview with the Registered Nurse (RN) (LL) on 5/5/25 at 9:30 a.m., RN LL confirmed that he does not provide a plan of care to outline how care and services will be provided to the patient. 3. During a home visit observation on 5/5/25 at approximately 3:30 p.m., for P#16, the home health admissions packet was reviewed. However, the packet failed to written instructions and information regarding care and treatments the agency will provide. During an in-home interview with P#16 on 5/5/25 at 4:00 p.m., P#16 confirmed that he did not have written information regarding care plan instructions. During an interview with the physical therapist (PT) (KK) on 5/5/25 at 4:10 p.m., PT KK confirmed that he does not provide written instructions of plan of care to outline how care and services will be provided to the patient. During an office interview on 5/7/25 at approximately 10:00 a.m., the Administrator confirmed that the agency does not provide any written instructions to include visit schedule, medication schedule and instructions, and care and treatments the agency will provide. He also stated that upon admission, the staff ask the patients if they want the information and if they say they want the information the agency will provide the information but if the patient declines the information, then the agency will not provide the information.”