St Rita Home Health Care, Inc.

“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 OASIS Error Summary report and Staff interview, it was determined in 2 of 39 reports submitted for the last 12 months, the Agency failed to submit all timely reports, resulting in a warning. Finding include: 1. The OASIS Error Summary report for 10/01/23 - 09/08/24, was reviewed on 09/10/24 at 11:30 AM. The report included error # -3330 for 2 of 39 submissions, 5.13 % of the reports submitted were more than 30 days after the M0090. 2.During an interview with the Administrator, on 09/11/24 at 11:50 AM, the Administrator confirmed that the error occurred.”

“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 record review and staff interview, it was determined that in 3 of 7 (Pts. #1, 2 and 4) the Agency failed to ensure that services were provided, according to the POC. 2. Pt. #2 was admitted to the Home Health Services on 04/11/24 with the diagnoses of: Hypertensive Heart Disease and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 09/10/24. The clinical record contained a POC dated 06/10/24 and 08/09/24, that required diabetic supplies and the SN to assess the patient, 1 time a week for 9 weeks. A home visit interview was conducted with Pt. #2, on 09/10/24 at 2:00 PM. Patient #2 stated he did not have a sharp container (diabetic supply) and was disposing his sharps into his garbage. 3. Pt. #4 was admitted to the Home Health Services on 08/16/24 with the diagnoses of: Polyosteoarthritis Unspecified and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 09/10/24. The clinical record contained a POC dated 08/16/24, that required diabetic supplies and the SN to assess the patient’s weight, 1 time a week for 9 weeks. The SN visit notes dated 08/19/24, 08/27/24 and 09/03/24 lacked the patient’s weight and the sharp container (diabetic supply) for disposing the patient’s sharps. 4. Pt. #6 was admitted to the Home Health Services on 05/08/24 with the diagnosis of: Hemiplegia following Cerebral Infarction. The clinical record was reviewed on 09/11/24. The clinical record contained a POC dated 05/08/24, that included a verbal order dated 05/10/24 for MSW services. As of 09/12/24, the MSW visit was not conducted. 5. The findings were confirmed, during the interview with the Administrator and Assistant Director of Nursing, on 09/11/24 between 2:00 PM – 3:00 PM. Findings include: 1. Pt. #1 was admitted to Home Health Services on 04/03/24 with the diagnosis of: Epilepsy and Hypertensive Heart and Chronic Kidney Disease with Heart Failure. The clinical record was reviewed on 09/10/24. The PsOC effective 06/02/24 and 08/01/24, required 2 SN visits, every 1 week for 9 weeks. The SN visit notes documented 1 SN visit from 07/17/24 to 09/06/24. The PsOC effective 06/02/24 and 08/01/24, required Aide visit, 5 hours/day, 6 days/week for 9 weeks. The Aide visit notes documented 5 visits from 07/29/24 to 08/09/24 and from 08/26/24 to 08/31/24. The clinical record lacked documentation that the SN and Aide provided services, as ordered. There was no modification in Physician orders. The POC effective 06/02/24, required: “…. Notify physician if weight gain x 5 or loss x 1 week.” The following SN assessments documented a weight of 252.30 lbs. on 07/17/24, 245.70 lbs. (6 lbs. weight difference) on 07/23/24 and 250.90 lbs. (5.2 lbs. weight difference) on 7/31/24. The clinical record lacked documentation that the Physician was notified of the weight change.”

“Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This Element is not met as evidenced by: Based on clinical record review and Staff interview, it was determined that in 2 of 3 (Pts. #1 and 3) clinical records reviewed wherein the Pt. received Home Health Aide services, the Agency failed to ensure that Aide provided services, as directed on the Home Health Aide Care Plan. Findings include: 1. Pt. #1 was admitted to Home Health Services on 04/03/24 with the diagnosis of Epilepsy. The clinical record was reviewed on 09/10/24. The “HHA Care Plan”, effective 06/02/24 and completed by the RN, required the Aide to provide/assist with bath. The Aide visits from 07/15/24 to 07/20/24, lacked documentation that the Aide provided/assisted with bath during those visits. The “HHA Care Plan, effective 08/01/24 and completed by the RN, required Aide to assist with bath and “…. check and record BP, HR, weigh daily….” The Aide visits from 08/02/24 to 08/06/24 and from 09/04/24 to 09/07/24, lacked documentation that the Aide provided/assisted with bath and assessed BP, HR and weight during those visits. 2. Pt. #3 was admitted to Home Health Services on 08/19/24 with the diagnosis of Ataxia following Cerebral Infarction. The clinical record was reviewed on 09/10/24. The “HHA Care Plan” effective 08/19/24 and completed by the RN, required the Aide to provide shower or bed bath as needed if not able to shower. The following Aide notes dated 08/30/24, 09/04/24 and 09/06/24, lacked documentation that the Aide provided shower or bed bath during those visits. 3. During an interview with the Administrator and Assistant Director of Nursing on 09/11/24 at 2:30 PM, both confirmed the above findings.”