Benchmark Home Health Care

“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 review of the Agency’s Error Summary report and Staff interview, it was determined in 18 of 114 reports submitted for the last 12 months, the Agency failed to submit all timely reports. Finding include: 1. The Agency’s Error Summary report for 07/01/2024 thru 06/30/2025, was reviewed on 07/16/25 at 10:10 AM. The report included 33.52% of the OASIS reports were not submitted timely, resulting in a warning. 2. The above findings were confirmed, during the interview with the Acting Director of Nursing, on 07/16/25 between 9:30 AM and 10:40 AM.”

“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 clinical records reviewed and staff interview, the facility failed to ensure in 1 of 7 (Pt. #6) clinical records reviewed, the patient care was provided as ordered in the plan of care. Findings include: 1. Pt. #6 was admitted to the home health services on 01/02/25 with the diagnoses of “Non-prs chr ulcer oth prt L low leg limited to brkdwn skin”. The clinical record was reviewed on 07/15/25. The clinical record contained a POC dated 03/07/25, that required the SN to assess the patient 1 time a week for 9 weeks and instruct the patient on medication management. The SN failed to teach the patient regarding the new orders (dated 04/08/25) for Amoxicillin-Clavulate 875 mg one tablet by mouth daily for 10 days for wound infection. 2.The above findings were confirmed, during the interview with the Acting Director of Nursing, on 07/16/25 between 9:30 AM and 10:40 AM.”

“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 reviews and staff interview, the Agency failed to ensure in 3 of 7 (Pts. #4, 1 and 6) clinical records reviewed, the clinical records were complete and accurate. Findings include: 2. Pt. #1 was admitted to the home health services on 03/07/25 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 07/15/25. The clinical record included a communication note, instead of the required SN visit note for the week of 05/25/25 (week #4). The clinical record lacked the recertification orders for the Physical therapy services provided on July 10 and 15, 2025 (weeks #1 and 2). 3. Pt. #6 was admitted to the home health services on 01/02/25 with the diagnoses of “Non-prs chr ulcer oth prt L low leg limited to brkdwn skin”. The clinical record was reviewed on 07/15/25. The clinical record contained a POC dated 03/07/25, that required woundcare. The clinical record contained SN visit notes dated April 17, 2025 thru May 3, 2025, that lacked documentation of the weekly left leg wound measurements. 4. The above findings were confirmed, during the interview with the Acting Director of Nursing, on 07/16/25 between 9:30 AM and 10:40 AM. Findings include: 1. Pt. #4 was admitted to home health services on 01/22/25 with the diagnosis of Hypertensive Chronic Kidney Disease with Stage 1 to 4 Unspecified Chronic Kidney Disease. The clinical record was reviewed on 07/15/25. The clinical record included a “Skilled Nurse Visit” note dated 06/24/25. The RN documented on the nurse visit note that care coordination was done with a “Clinical manager” and, recorded the name of a person who was not employed at this Agency, referring to this person as the (DON)Director of Nursing. The clinical record also included the document, “HHA Supervisory Visit.” The RN recorded on the HHA Supervisory note dated 06/24/25, the name of a LPN, instead of the HHA conducting the visits. The LPN has not provided any Aide services for Pt. #4.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on clinical record review and staff interviews, the Agency failed to ensure that the RN conducted the initial comprehensive assessment within 48 hours of the referral. This was found in 3 of 7 (Pts. 2, #3 and #4) clinical records reviewed. Findings include: 1. Pt. #2 was admitted to home health services on 01/31/25 with the diagnosis of Malignant Neoplasm of the Bladder. The clinical record was reviewed on 07/15/25. The clinical record included a “Referral Sheet” with orders for SN visits received via fax by the Agency on 01/18/25. The clinical record lacked an RN initial comprehensive assessment within 48 hours of the referral, or a Physician-ordered SOC date. 2. Pt. #3 was admitted to home health services on 07/11/25 with the diagnosis of Alzheimer’s Disease Late Onset. The clinical record was reviewed on 07/16/25. The clinical record included the “Document of Face-to-Face Encounter” with orders for SN, PT and OT and received via fax by the Agency on 07/03/25. The clinical record lacked an RN initial comprehensive assessment with 48 hours of the referral, or a Physician-ordered SOC date. 3. Pt. #4 was admitted to home health services on 01/22/25 with the diagnosis of Hypertensive Chronic Kidney Disease with Stage 1 to 4 Unspecified Chronic Kidney Disease. The clinical record was reviewed on 07/15/25. The clinical record included a Physician script with orders for PT dated and faxed to the Agency on 01/17/25. The clinical record lacked an RN initial comprehensive assessment within 48 hours of the referral, or a Physician-ordered SOC date. 4. During the entrance interview conducted with the Acting Administrator/Director of Nursing and the Acting Director of Nursing on 07/14/25, both stated the initial comprehensive assessment is conducted within 48 hours of the referral. During an interview with them on 07/16/25 at 12:30 PM, the above findings were 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 a review of the Agency’s Pt. admission folder, clinical record review and staff interviews, the Agency failed to provide information regarding the Clinical Manager (Director of Nursing) and their contact information. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Agency Pt. admission folder was reviewed on 07/14/25 at 10:30 AM. The folder lacked information identifying the name and contact information of the Clinical Manager. Pt. #1. SOC 03/07/25. Pt. #2. SOC 01/31/25. Pt. #3. SOC 07/11/25. Pt. #4. SOC 01/22/25. Pt. #5. SOC 06/21/25. Pt. #6. SOC 01/02/25. Pt. #7. SOC 09/24/24. 2. During an interview with the Acting Administrator/Director of Nursing and RN/Acting Director of Nursing on 07/16/25 at 12:30 PM, it was stated that the same admission folder is given to all Pts. at SOC and confirmed that the folder lacked the contact information of the Clinical Manager.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on clinical records review and staff interview, the Agency failed to ensure, in 1 of 2 (Pt. #7) discharged clinical records reviewed, a completed discharge summary was sent to the physician. Findings include: 1. Pt. #7 was admitted to the home health services on 09/24/24 with the diagnosis of Essential Hypertension. The clinical record was reviewed on 07/15/25. The clinical record included a PT discharge summary indicating patient was discharged from the Agency on 05/19/2025. The record lacked documentation that the discharge summary was sent to the physician. 2. The above findings were confirmed, during the interview with the Acting Director of Nursing, on 07/16/25 between 9:30 AM and 10:40 AM.”