Simply Home Health Healthcare Partners Medical LLC

“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 a review of the Agency’s OASIS submission report and staff interview it was determined that the Agency failed to submit OASIS assessment within the required time frame. Findings include: 1. The Agency’s past 12 months OASIS submission report was reviewed on 08/07/24. The report contained information that out of the 826 Agency’s OASIS assessment reports, 9 (1.09%) were submitted beyond the required time frame of 30 days. 2. During an interview with the Alternate Clinical Manager and Quality Assurance Nurse on 08/08/24 at 10:30 AM. The Alternate Clinical Manager and Quality Assurance Nurse confirmed the Agency’s late OASIS submission.”

“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 review and Staff interview, it was determined in 4 of 7 (Pts. # 5, 7, 4 and 6) clinical records reviewed, the patient care was not provided as ordered in the plan of care. 3. Pt. #4 was admitted to the Home Health Services on 06/12/24 with the diagnosis of: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 08/06/24. The clinical record contained a POC dated 06/12/24, that required the SN to assess the patient’s weight, 1 time a week for 9 weeks. The SN lacked the weight assessment for the entire 9 week certification period and the plan of care was not modified. The same POC required Physical Therapy 1 time a week for 1 week, 2 times a week for 2 weeks and 1 time a week for 1 week. The patient did not receive physical therapy, week #3. The plan of care was not modified. 4. Pt. #6 was admitted to the Home Health Services on 01/16/24 with the diagnosis of: Pressure Ulcer Right Buttock Stage 2. The clinical record was reviewed on 08/07/24. The clinical record contained a recertification POC dated 03/16/24, that required SN to assess the patient, 1 time a week for 9 weeks and to weigh the patient every visit. The SN lacked the weight assessment for the entire 9 week certification period. The plan of care was not modified. 5. The findings were confirmed the during the interview with the Alternate Clinical Manager and Quality Assurance Nurse, on 08/07/24 between 10:30 AM – 11:40 AM and on 08/08/24 between 10:00 AM and 11:00 AM. Findings include: 1. Pt. #5 was admitted to Home Health Services on 06/17/24 with the diagnosis of: Type 2 Diabetes Mellitus with diabetic polyneuropathy. The clinical record was reviewed on 08/06/24. The clinical record contained a POC for certification period 06/17/24 to 08/15/24, that required the SN frequency of 1 time a week for 9 weeks and for SN to check and record every SN visit and notify MD if random blood sugar level is greater than 250 mg/dl or less than 75 mg/dl, if fasting blood sugar is greater than 200 mg/dl or less than 70 mg/dl. Pt # 5 clinical record contained SN visit notes dated 07/01, 07/08, 07/22 and 07/29/24 that lack documentation for blood sugar levels. 2. Pt.# 7 was admitted to Home Health Services on 03/14/24 with the diagnosis of: Essential Hypertension. The clinical record was reviewed on 08/07/24. The clinical record contained a POC for certification period 03/14/24 to 05/12/24, that required the SN frequency of 1 time a week for 9 weeks. The clinical record contained missed visits for weeks # 5 and # 6 of certification period. No modification physician orders were found in the record.”