Frontliners 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 review of the Error Summary report and staff interview, it was determined that in of 54 of 219 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 10/1/24 to 2/26/25 (12 months), was reviewed on 3/25/25. The report included a warning for Error # -3330. The Error included 54 (24.66 %) of 219 assessments that were submitted late. 2. During staff interviews with the Assistant (Alternate ) Administrator and Agency Supervisor on 3/26/25 at 12:30 PM, the Agency Supervisor confirmed the above findings.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on clinical record review, and staff interviews, it was determined for 4 of 7 Pts. (Pts. #4, 5, 6 and 7) the Agency failed to ensure that the comprehensive assessments included a complete review of body systems. 2. Pt. #5 was admitted to home health services on 12/27/24 with diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 3/25/24. The comprehensive assessment dated 2/21/25 lacked documentation of the assessments for genitourinary, endocrine, cardiac, respiratory, gastrointestinal, and musculoskeletal systems. 3. Pt. #6 was admitted to home health services on 3/23/24 with diagnosis of Encounter for change or removal of non-surgical wound. The clinical record was reviewed on 3/25/24. The comprehensive assessment dated 5/17/24 lacked documentation of the assessments for genitourinary, endocrine, cardiac, respiratory, gastrointestinal, and musculoskeletal systems. 4. Pt. #7 was admitted to home health services on 4/21/24 with diagnosis of Type 2 Diabetes Mellitus. The clinical record was reviewed on 3/26/24. The comprehensive assessment dated 6/18/24 lacked documentation of the assessments for genitourinary, cardiac, respiratory, gastrointestinal, and musculoskeletal systems. 5. During staff interviews with the Assistant (Alternate ) Administrator and Agency Supervisor on 3/26/25 at 10:45 AM and 12:30 PM, the administrative staff confirmed the above findings. Findings include: 1. Pt. #4 was admitted to home health services on 12/4/24 with the diagnosis of Venous Insufficiency (Chronic) (Peripheral). The clinical record was reviewed on 3/25/24. The comprehensive assessment dated 1/28/25 lacked documentation of the assessments of the genitourinary, endocrine, cardiac, respiratory, gastrointestinal, and musculoskeletal systems.”

“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 clinical record reviews, policy review and staff interviews, it was determined that for 1 of 7 (Pt. #4) clinical records reviewed, the Agency failed to ensure that care and services provided were according to Physician orders and as indicated in the POC. Findings include: 1. Pt. #4 was admitted for home health services on 12/4/24 with the Cutaneous Abscess of the Groin and Non-pressure Chronic Ulcer Unspecified Part of Right Lower Leg with Fat Layer Exposed. The clinical record was reviewed on 3/25/25. The clinical record contained, “Order/Telephone Order” dated 3/10/25, requiring: “Posterior neck wound: Cleanse with normal saline, pat dry, and apply skin prep to the peri-wound. If the wound is dry, leave it open to air with skin prep applied…Right breast and left groin wounds: Lightly tuck Prisma AG-collagen to the depth of the wound. Fill wounds with Vashe-moistened ribbon. Cover with drawtext and secure with bordered foam…” The “Wound Care Worksheets” included the same documentation of treatment provided for the following dates, 3/12/25, 3/14/25 and 3/19/25: “Posterior neck, Dehisced Surgical wound, treatment: Apply Acquacel AG then cover with bordered foam dressing… Right breast: Subcutaneous abscess, treatment: Pack the wound with mesalt leave the tail out for easy removal…Left Groin: Subcutaneous abscess, treatment: Pack the wound with mesalt …cover with dry gauze, change daily…” The RN failed to follow the wound treatment ordered by the Physician. 2. During an interview with the Agency Supervisor and the Assistant (Alternate)Administrator on 3/26/25, the Agency Supervisor stated all treatments provided by the nurse is documented on the Wound Notes under “Treatment Order.” It was also stated that all care, treatment, and services should have an order from the Physician. During the same interview, the above finding was confirmed.”

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on review of the Agency’s Pt. admission folder, observation during home visits, clinical record reviews, and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./patient’s representative information regarding the Agency Supervisor. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 3/24/25. The folder lacked the name and information to contact the Agency Supervisor. 2. The following home visits were conducted on 3/24/25 and 3/25/25: Patient #1. SOC 3/18/25. Patient #3. SOC 2/3/25. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Agency Supervisor. 3. The following clinical records were reviewed on 3/25/25 and 3/26/25: Pt. #1. SOC 3/18/25. Pt. #2. SOC 1/11/25. Pt. #3. SOC 2/3/25. Pt. #4. SOC 12/4/24. Pt. #5. SOC 12/27/24. Pt. #6. SOC 3/23/24. Pt. #7. SOC 4/21/24. The clinical records lacked documentation that the Pt./patient’s representative was provided the name and contact of the Agency Supervisor. 4. During staff interviews with the Assistant (Alternate ) Administrator and Agency Supervisor on 3/26/25 at 12:30 PM, the Agency Supervisor confirmed the Agency failed to provide the Pt./patient’s representative information regarding the Agency Supervisor.”