Greenpath Health Group, 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 the review of the OASIS Error Summary report and staff interview, it was determined in 81 of 336 reports submitted for the last 12 months, the Agency failed to submit reports within the 30 day timeframe, resulting in a warning. Finding include: 1. The Error Summary report for 06/01/23 -05/31/24, was reviewed on 06/11/24 at 11:30 AM. The report included error # -3330 for 81 late submissions, 24.11% of the OASIS reports submitted were more than 30 days after the M0090. 2. During an interview with the Acting Administrator on 06/12/24 at 10:35 AM, the Acting Administrator confirmed that the error occurred and the Agency uses an outside Biller.”

“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 a review of clinical records and Staff interview, it was determined that for 5 of 7 (Pts. #1, 2, 3, 5 and 6) clinical record reviewed, the Agency failed to ensure forms and records were complete and accurate. Findings include: 1. The following clinical records were reviewed on 6/11/24 at 9:15 AM to 2:00 PM: Pt. #1. SOC: 04/26/24 Pt. #2. SOC: 05/17/24 Pt. #3. SOC: 04/19/24 Pt. #5. SOC: 06/04/24 Pt. #6. SOC: 02/21/24 The above-mentioned records contained the form “Notice of Medicare Non-Coverage” that at the SOC, the Pt./patient’s representative had to complete. The forms were signed by the Pt. or representative, but the areas containing “Date of Birth, Effective Date of Coverage your current home health services will end, and Date Signed” that were to be filled out was left blank. 2. Pt. #1 was admitted for home health services on 4/26/24 with a Diagnosis of Mixed Hyperlipidemia. The clinical record was reviewed on 06/11/24 and contained a comprehensive assessment completed by the Registered Nurse on SOC and recorded a weight of 170 pounds. The record also included an SN note dated 5/2/24 which indicated a weight gain of 6 pounds. During an interview with the Director of Nursing/SN for Pt. #1 on 6/12/24, it was stated, “the weight recorded on the comprehensive assessment was inaccurate; it should have been 179 pounds instead of 170 pounds, and we’re going to submit an addendum” and therefore there was no need to notify the physician of the weight gain. 3. Pt. #3 was admitted for skilled home health services on 4/19/24 with a Diagnosis of Fibromyalgia. The clinical record was reviewed on 06/11/24 and contained an SN note on 4/30/24 indicating a weight gain of 35 pounds. During an interview with the Director of Nursing/SN, it was stated that the weight recorded visit note dated 4/30/24 was inaccurate and therefore there was no need to notify the physician of the weight gain. 4. During an interview with the Administrator, Acting Administrator and Office Intake on 6/12/24 at 11:50 AM, it was stated that all areas of forms and records should be filled out completely and accurately. During the same interview, the above findings were confirmed.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on a review of clinical records and Staff interview, it was determined for 4 of 7 (Pts. #1, 2, 3, and 7) clinical records reviewed, the Agency failed to ensure Pts. were informed of the frequency of visits provided by each discipline. Findings Include: 1. The following clinical records were reviewed on 06/11/24. Pt. #1. SOC: 04/26/24. Pt. received SN and Physical Therapy services. Pt. #2. SOC: 05/17/24. Pt. received SN and Physical Therapy services. Pt. #3. SOC: 04/19/24. Pt. received SN, Physical Therapy and Occupational Therapy services. Pt. #7. SOC: 02/01/24. Pt. received SN, MSW and Physical Therapy services. The records lacked documentation that at the SOC, the Pt./patient’s representative participated or was notified of each discipline’s frequency of visits, prior to providing Pt. care and services. 2. During an interview with the Administrator and Acting Administrator and Intake on 06/12/24 at 11:50 AM, the above findings were confirmed.”

“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 the clinical record review and Staff interview, it was determined in 2 of 7 (Pts. #6 and 7) clinical records reviewed, the patient care was not provided as ordered by the physician. Findings include: 1. Pts. #6 was admitted to the Home Health Services on 04/05/24 with the diagnosis of Alzheimer’s Disease with Early Onset. The clinical record was reviewed 06/11/24. The clinical record contained a POC dated 04/05/24 that required SN to assess the patient 1 time a week for 5 weeks. The clinical record lacked the SN visit for the week of 04/07/24 (week #2). 2. Pts. #7 was admitted to the Home Health Services on 02/01/24 with the diagnosis of Malignant Neoplasm of Prostate. The clinical record contained a POC dated 02/01/24, that required the SN to notify the Physician of weight gain greater than 5 lbs per week. The SN documented on 02/01/24 a weight of 140 lbs and on 02/06/24 a weight of 146 lbs. The physician was not notified of the 6 lbs weight gain. 3. The findings were confirmed during the interview with the Acting Administrator and Director of Nursing on 06/12/24 between 1:00pm -2 :00pm.”

“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 record review and staff interview, it was determined in 1 of 2 (Pt. #7) discharged records reviewed, the discharge summary was not completed as required. Findings include: 1.Pt. #7 was admitted to the Home Health Services on 02/01/24 with the diagnosis of Malignant Neoplasm of Prostate. The discharged clinical record was reviewed on 06/11/24. The discharged clinical record lacked the summary of the wound care and foley catheter care provided by Agency. 2. The findings were confirmed during the interview with the Acting Administrator and Director of Nursing on 06/12/24 between 1:00pm -2 :00pm.”