Pruitthealth @ Home-Albany

“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, agency policy, and staff interview, it was determined that the agency failed to electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the State Agency every 30 days. Findings include: Review of the policy titled “Reporting OASIS Information,” undated, revealed the following: Policy The Agency will report required data collected for the Outcome and Assessment Information Set (OASIS) items. Procedure The Home Health Agency (HHA) should encode and electronically transmit each completed OASIS assessment to the State agency or the CMS OASIS contractor, regarding each beneficiary with respect to which such information is required to be transmitted, within 30 days of completing the assessment of the beneficiary. Review of CMS report ran on 5/1/24 for period 2/6/23 to 1/23/24 titled “HHA Error Summary by Agency”, revealed the agency failed to transmit OASIS data to the State Agency within 30 days. An interview was conducted with the Administrator on 5/13/2024 at 1:00 p.m. The Administrator confirmed OASIS reports had not been submitted to CMS within 30 days of completing the assessments.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on clinical record reviews and staff interview, it was determined the agency failed to provide services as ordered by the physician in the plan of care for three patients (P) (P#4, P#5, P#6) of three sampled patients with wound care management. Findings include: 1. Review of clinical record revealed that P#5 was admitted on 4/23/2024 with diagnosis of pressure ulcer (an open wound on your skin caused by a long period of constant pressure to a specific area of the body) to buttock, congestive heart failure (heart can’t pump blood well), and type 2 insulin dependent diabetes mellitus (high blood sugar). Plan of care dated 4/23/2024 revealed skilled nurse (SN) to perform the following: SN: assessment and wound care to the wound on buttock as follows: cleanse wound with soap and water, pat dry, cover with bordered foam dressing. Change dressing twice a week and as needed. May refer to wound care center if wound shows little or no improvement within 30 days. SN: review patient’s blood sugar log at every visit and notify Primary Care Provider (PCP) with blood sugar less than 60 or greater than 300. SN: monitor patient’s weight gain if able to balance on scale of 2-3 pounds in one week or 5 pounds in one day. Review of the SN visit notes dated 4/23, 4/25, 4/30, and 5/3/2024 failed to reveal wound measurements and progress or lack of progress of wound status, blood sugar level, and patient’s weight. 2. Review of clinical record for P#6 revealed that patient was admitted on 4/4/2024 with diagnosis of chronic venous stasis ulcer to right ankle (open wounds on the legs or ankles that don’t heal easily due to poor blood circulation in the veins). Plan of care dated 4/4/2024 revealed the skilled nurse (SN) to provide assessment and wound care to right ankle as follows: cleanse right ankle wound with sterile saline, use exufiber AG (a sterile non-woven gelling fibre design with an antimicrobial action against a broad range of wound relevant pathogens) as primary dressing, oil emulsion dressing, apply 4x4’s ABD pad and wrap with Unna boot, Change dressing twice a week. Review of SN visit notes dated 4/16, 4/19, 4/24, and 4/26/2024 failed to reveal wound measurements and progress or lack of progress of wound status. 3. Review of clinical record for P #4 revealed that patient was admitted on 4/12/2024. Review of the Resumption Of Care (ROC) orders dated 4/26/24 revealed that patient has a wound to right lateral left toe. SN to assess and provide wound care as follows: cleanse wound with normal saline or wound cleanser, pat dry, cover with dry gauze, and bordered foam dressing. Change dressing twice a week. Review of SN visit notes dated 4/25, 4/30, 5/2 and 5/8/24 failed to reveal wound measurements and progress or lack of progress of wound status. An office interview was conducted on 5/14/2024 with the Administrator at 1:00 p.m., the Administrator verbalized that wound measurements are performed on weekly basis and confirmed that visit notes for P#4 and P#6 lacked wound measurements and visit notes for P#5 lacked wound measurements, blood sugar level, and patient’s weight.”