Adoration 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 policy titled “OASIS Data, Capture, Transmission, Verification, Display and Reports,” the Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report, 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 Data, Capture, Transmission, Verification, Display and Reports,” revised 03/01/21 revealed the following: Procedure: 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. Review of CMS report titled “HHA Error Summary by Agency,” with report period of 05/01/2024-05/01/2025 and run date of 05/27/2025, revealed the agency failed to transmit OASIS data to CMS system within 30 days. On 06/30/2025 at approximately 11:30 a.m., during an in-office interview, Registered Nurse (RN AA), who is temporarily the “acting Administrator”, revealed that she was unaware that the 30-day OASIS submission timeframe requirements were not met during the time frame of 05/01/2024 through 05/01/2025. RN AA acknowledged that she is aware that there is a 30-day submission timeframe for submitting OASIS.”

“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 review, staff interviews and agency policy “Plan of Care (POC),” it was determined that the agency failed to obtain a blood glucose check order for one patient (P) (P#2) with diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) and failed to include diagnosis, goals, and interventions with end stage renal disease (a condition where the kidney reaches advanced state of loss of function) for one patient (P#11) of 11 sampled patients. Findings include: Review of the policy titled “Plan of Care (POC) (Policy Number: 2.1.007),” revised 4/01/25, reveals the following: Purpose: To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician/authorized practitioner’s orders are followed. Policy: Each patient has an individualized plan of care developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. Procedure: 2. The POC includes: i. Patient specific interventions and education; measurable outcomes and goals identified by the agency and patient. k. Patient’s risk for emergency department visits and re-hospitalization including interventions that address underlying risk factors. 1. Review of the plan of care (POC) for P#2 (certification period (start of care) of 11/25/2024 to 1/23/2025) revealed P#2 was admitted to the agency on 11/25/2024, with a diagnosis of type 2 diabetes mellitus (type 2 diabetes happens when the body cannot use insulin correctly and sugar builds up in the blood) insulin dependent. The agency failed to obtain a blood glucose check order on the POC and failed to indicate the assessment and monitoring of P#2’s blood sugar on the POC. 2. Review of the plan of care (POC) for P#11 (certification period (start of care) of 6/11/2025 to 8/9/2025) revealed P#11 was admitted to the agency on 6/11/2025., The agency failed to include a diagnosis of end stage renal disease on the POC for P#11. The agency failed to address goals, and interventions, on the POC to assess and monitor the right upper chest permanent catheter (connection that a surgeon makes between an artery and a vein to make it possible to receive hemodialysis) for dialysis for bleeding and signs of infection. During a phone interview with Registered Nurse (RN) AA on 7/01/2025 at 2:13 p.m., RN AA confirmed that the agency failed to address interventions on diagnosis of end stage renal disease on P#11 POC because she was not aware that she had to obtain order to assess and monitor for bleeding and infection at upper right chest permanent catheter site for dialysis placed on 4/29/25. RN AA also said that she was there for wound care. During a phone interview with RN BB on 7/01/2025 at 2:47 p.m., RN BB confirmed that the agency failed to obtain blood glucose check order to monitor P#2, blood sugar. On 7/01/2025 at 3:29 p.m., an interview conducted at conference room with the regional director covering for the Administrator who acknowledged that the agency failed to include interventions for the diagnosis of end stage renal disease for P#11, also failed to obtain blood glucose order to check for P#2 blood sugar.”