Metro Home Health Care NFP

“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 review of the Error Summary report and staff interview, it was determined that in of 22 of 480 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 01/01/24 to 12/31/24 (12 months), was reviewed on 01/27/25. The report included a warning for Error # -3330. The Error included 22 (4.78 %) of 460 assessments that were submitted late. 2. During staff interviews with the Administrator, Director of Nursing, and Clinical Supervisor on 01/29/25 at 11:30 AM, the administrative team confirmed the above findings.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on review of clinical records and staff interviews, it was determined in 2 of 7 (Pts. #2 and 4) clinical records reviewed, the Agency failed to ensure staff provided services as ordered by the Physician and/or indicated on the POC. 2.Pt. #4 was admitted to the Home Health Services on 12/07/24 with the diagnosis of: “Unspecified dementia, moderate, without beh/psych/mood/anx”. The clinical record was reviewed on 01/28/25. The clinical record contained a POC dated 12/07/24, that required the SN 1 time a week for 9 weeks, to assess the patient’s heart rate and instruct the patient on self management. The SN failed to instruct the patient/caregivers regarding signs/symptoms the low heart rate of 50, on 01/24/25 (week #8). 3.The above findings were confirmed, during the interviews with the Administrator, Director of Nursing, and Clinical Supervisor, on 01/29/25 between 10:00 AM and 11:30 AM. Findings include: 1. Pt. #2 was admitted for Home Health Services on 01/17/25 with the diagnosis of Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 01/28/25. The record included the POC for the certification period of 01/17/25 to 03/17/25 that required the SN to assess 1 time a week for 9 weeks diabetic status, identify any signs and symptoms of impaired diabetic function, report significant changes to physician. SN to monitor blood sugar levels to assess efficacy of medication and dietary therapy; coordinate care with physician for need to change plan of care. The SN visit notes, dated 01/17/25 and 01/21/25, lacked the assessment of the blood glucose.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on clinical record review, home visit observations and Staff interview, it was determined that in 3 of 7 (Pts. #3, 4 and 5) clinical records reviewed, the Agency failed to ensure the clinical records were complete and accurate. Findings include: 1. Pt. #3 was admitted to the Home Health Services on 01/24/25 with the diagnoses of: Parkinson’s disease without dyskinesia, without mention of fluctuations. The clinical record was reviewed on 01/28/25. A home visit was conducted on 01/28/25 at 11:05 AM, with the Physical Therapist (PT) and the PT visit note was incomplete. The PT was observed assessing the HR of 51. The Patient reported the “breaks” on the rolling walker were not working properly. The PT visit notes of 01/28/25 lacked documentation regarding the walker and decreased heart rate. 2. Pt. #4 was admitted to the Home Health Services on 12/07/24 with the diagnosis of: “Unspecified dementia, moderate, without beh/psych/mood/anx”. The clinical record was reviewed on 01/28/25. The clinical record contained a POC dated 12/07/24, that required the SN to assess the patient’s heart rate and blood glucose, 1 time a week for 9 weeks. The SN failed to document in her SN visit note the patient’s blood glucose on 12/07/24 (week #1). During the interview with the DON and Supervisor, it was stated the blood glucose was documented in the home but was not included in the clinical record of the SN visit note. 3. Pt. #5 was admitted to the Home Health Services on 10/16/24 with the diagnoses of: Bilateral Primary Osteoarthritis of knee and Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 01/28/25. The clinical record contained a POC dated 10/16/24, that required the SN to assess the patient, 1 time a week for 5 weeks and 1 time every other week. The clinical record lacked documentation of the order for the extra RN visit conducted 12/03/24 (week #8). 4. The above findings were confirmed, during the interview with the Administrator, Director of Nursing, and Clinical Supervisor, on 01/29/24 between 10:00 AM and 10:30 AM.”

“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 the clinical records reviewed, home visit observations and Staff interview, it was determined in 3 of 7 (Pts. #1, 3, and 6) clinical records reviewed, the PsOC failed to included all the requirements. 2. Pt. #3 was admitted to the Home Health Services on 01/24/25 with the diagnoses of: Parkinson’s disease without dyskinesia, without mention of fluctuations. The clinical record was reviewed on 01/28/25. The clinical record contained a POC dated 01/24/25, that lacked the patient’s hearing aids, documented on the initial assessment and observed during the home visit conducted on 01/28/25 at 11:05 AM, with the Physical Therapist (PT). 3. Pt. #6 was admitted to the Home Health Services on 05/09/24 with the diagnoses of: Acute systolic (congestive) heart failure. The clinical record was reviewed on 01/28/25 and included weekly weight monitoring ranging 130 lbs to 144 lbs, with the daily use of Furosemide 40 mg (diurectic/water pill). The clinical record-POC dated 05/09/24, lacked the weight parameters to be reported to the Physician. 4. The above findings were confirmed, during the interview with the Administrator, Director of Nursing, and Clinical Supervisor, on 01/29/24 between 10:00 AM and 10:30 AM. 1.Pt. #1 was admitted to Home Health Services on 12/28/24 with the diagnosis of Chronic Obstructive Pulmonary disease with (acute) Exacerbation. The clinical record was reviewed on 01/28/25. The medication list included Furosemide 20mg every other day. The record included weekly weights that ranged between 138 to 152 lbs. The POC for the certification period of 12/28/24 to 02/25/25, lacked the parameters to report to the Physician the weekly weights.”