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 Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by agency report, policy “OASIS Data 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 the policy titled “OASIS Data Capture, Transmission, Verification, Display and Reports” last revised 03/01/2021, revealed the following: Procedure: 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 01/01/2024-12/31/2024 and run date of 2/11/2025, revealed the agency failed to transmit OASIS data to CMS system within 30 days. During an in-office interview on 2/25/2025 at 12:07 p.m., the Executive Director revealed that she was aware that the 30-day OASIS submission timeframe requirements were not met during the time frame of 01/01/2024 through 12/31/2024. The Executive Director reported that the agency OASIS reviewing, and submission process was deferred due to complications with the agency’s workflow, specifically with staffing issues.”

“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 review of the policy titled “Plan of Care (POC),” clinical record reviews, and staff interview, it was determined the agency failed to ensure the plan of care included all medications and treatments related to pertinent diagnoses for two patients (P) (P#1 and P#15) of eighteen sampled patients. Findings include: Review of the policy titled “Plan of Care (POC),” Policy Number 2.1.007, revised 9/1/2024 reveals the following: Procedure: 2. The POC includes: f. Medications and treatments i. Patient specific interventions and education n. All patient care orders 1. Clinical record review reveals P#1 was admitted on 1/20/2025 with a diagnosis of rectal cancer, status post proctectomy on 1/7/2025 (a surgical procedure to remove all or part of the rectum). Patient was admitted to the home health agency with a Jackson-Pratt (JP) drain (a temporary tube and bulb that removes excess fluid from the body after surgery). P#1 had a surgically implanted port (a medical device that provides long-term access to a large vein, typically in the chest or arm) placed on 2/4/2025. Further review of the clinical record failed to reveal physician orders for care of the JP drain or the newly implanted port. 2. Clinical record review reveals P#15 was admitted to on 1/31/2025 with co-morbidities including long-term use of anticoagulants (medicines that increase the time it takes for blood to clot, commonly called blood thinners). On admission, P# 15 was prescribed Eliquis, a prescription blood thinner that prevents and treats blood clots. Further review of the clinical record failed to reveal interventions related to the increased risk of bleeding due to the Eliquis. An interview on 2/25/2025 at approximately 1:00 p.m., was conducted at the Home Health agency with the Executive Director (ED), who confirmed there were no physician orders for P#1’s JP drain or port and that the plan of care for P#15 failed to include bleeding precautions.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on review of policy titled “Plan of Care (POC),” clinical record review, and staff interview, it was determined the agency failed to provide care only as ordered by the physician for one patient (P) (P#1) of eighteen sampled patients. Findings include: Review of the policy titled “Plan of Care (POC),” Policy Number 2.1.007, revised 9/1/2024 reveals the following: Procedure: 7. Medications, treatments, and interventions are provided by qualified staff as ordered by the physician or authorized practitioner. Clinical record review reveals P#1 was admitted to the agency on 1/20/2025 with a diagnosis of rectal cancer. On 1/7/2025, P#1 had a proctectomy and a Jackson-Pratt (JP) drain was in place on admission to the home health agency. Review of Client Coordination Note Report, dated 2/12/2025, revealed P#1’s JP drain was flushed with normal saline by the agency nurse. Further review of P#1’s clinical record failed to reveal physician orders for flushing the JP drain. An interview on 2/25/2025 at approximately 1:00 p.m. was conducted at the Home Health agency with the Executive Director (ED), who confirmed the clinical record for P#1 lacked a physician order to flush the JP drain.”