Acacia Home Health Agency

“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 Error Summary report and staff interview, it was determined in 915 of 1,116 assessments submitted for the last 12 months, the Agency failed to submit all reports within 30 days, resulting in a warning. Findings include: 1. The Agency’s Error Summary report for 03/01/24 to 03/26/25, was reviewed on 04/08/25. The report included an error for 915 of 1,116 of OASIS assessments submitted (81.99 %) were submitted more than 30 days after the assessment was completed. 2. During an interview with the Administrator on 04/10/25 at 10:30 AM, the Administrator confirmed the late submissions.”

“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 interviews, it was determined for 4 of 7 (Pts. #5, #7, #1 and #4) clinical records reviewed, the Agency failed to ensure care was provided as ordered by the Physician as indicated in the POC. 3. Pt. #1 was admitted to home health services on 3/5/25 with diagnosis of Type 2 diabetes mellitus with hyperglycemia. The clinical record was reviewed on 4/8/25 and included the POC effective 3/5/25 which required: “Notify Physician of vital sign parameters out of range - Fasting Blood Sugar: greater than (>) 250mg/dl Less than () 300 mg/ dl”. The SN visit notes dated 3/12 and 3/19/25 lacked blood sugar assessment. 4. Pt. #4 was admitted to home health services on 11/26/24 with diagnosis of Type 2 diabetes mellitus with hyperglycemia. The clinical record was reviewed on 4/8/25 and included the POC effective 01/25/25 to 03/25/25 which required: “Notify Physician of vital sign parameters out of range - Fasting Blood Sugar: greater than (>) 250mg/dl Less than () 300 mg/ dl”. The SN visit notes dated 3/05 and 3/11/25 lacked blood sugar assessment. 5. During interviews with the Administrator and Agency Supervisor on 04/09/25 at 11:00 AM and on 04/10/25 at 10:30 AM, the findings of Agency staff not providing care as ordered by the Physicians in the POC were confirmed. Findings include: 1. Pt. #5 was admitted to home health services on 3/7/25 with the diagnosis of Type 2 Diabetes Mellitus with Diabetic Neuropathy. The clinical record was reviewed on 4/7/25 and included the POC effective 3/7/25 which required: “Orders/Treatment… blood glucose monitoring…Nursing Goals: Patient will maintain blood sugar within normal range by the end of episode as evidenced by readings within therapeutic range.” The record also included the initial comprehensive assessment completed by the RN on 3/7/25, which included the documentation, “SN will continue to monitor vital signs and blood sugar every visit and notify MD of any significant findings…” As of 4/9/25, the SN Teaching/Training notes dated 3/11/25, 3/18/25, 3/25/25 and 4/1/25 lacked documentation of blood glucose monitoring results. 2. Pt. #7 was admitted to home health services on 7/19/24 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 4/8/25. The record included a POC for the certification period of 7/19/24 to 9/16/24, which was lacked the Physician’s signature.”

“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 reviews, Agency policy review, and staff interviews, it was determined that for 2 of 7 (Pts. #5 and #7) clinical records reviewed, the Agency failed to ensure that the RN conducted the initial comprehensive assessment within 48 hours of the referral. Findings include: 1. Pt. #5 was admitted to home health services on 3/7/25 with the diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 4/8/25. The clinical record contained a Physician Encounter document with the service date of 3/1/25, which received by the Agency on 3/3/25 with orders for SN, PT, Home Health Aide and MSW services. The clinical record lacked an RN initial comprehensive assessment within 48 hours of the referral, or a Physician-ordered SOC date. 2. Pt. #7 was admitted to home health services on 7/19/24 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 4/8/25. The clinical record contained a Physician Encounter document with the service date of 7/11/24 with orders for SN and PT (refused). The clinical record lacked an RN initial comprehensive assessment with 48 hours of the referral, or a Physician-ordered SOC date. 3. The Agency policy titled “Client Admission Process” was reviewed on 4/9/25 and required, “7. Each client referred to the agency shall be evaluated by a Registered Nurse/Therapist to determine the immediate care and support the needs of the client…The initial assessment will be completed within 48 hours of referral or within 48 hours of the client’s return home, or on the physician ordered start of care date…” 4. During an interview with the Administrator and Agency Supervisor on 4/9/25 at 10:30 AM, it was stated that the RN should conduct the initial comprehensive assessment within 48 hours of the referral or the Physician-ordered SOC date. During the same interview, the above findings were confirmed.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on clinical record review, Agency policy review and staff interview, it was determined that for 1 of 1 (Pt. #5) Pts. wherein MSW services were provided, the Agency failed to ensure that concerns are communicated/coordinated within the healthcare team to ensure Pt. needs were identified and addressed. Findings include: 1. Pt. #5 was admitted to home health services on 3/7/25 with the diagnosis of Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 4/8/25. The MSW note “Social Work Discharge” dated 3/22/25 included the documentation, “Summary/Problem Resolved/Status: A service referral was completed with Pathlight Program at (phone number) to help patient get assistance to help decrease the stressors that is affecting the patient health. MSW also left message for patient’s daughter to contact ADDUS Homecare to be the preferred caretaker at (phone number) …” The clinical record lacked documentation of coordination between the Home Health Agency, the Pt. or Pt. representative and the external organizations related to the referral of services made by the MSW. 2. The Agency policy “Coordination of Client Services” was reviewed on 4/9/25 and required, “To ensure services are coordinated between members of the interdisciplinary team…To establish effective interchange, reporting and coordination of client care does occur. 6. Care conference will be documented on the Care Conference Summary form or in the progress note. A written summary report of services provided and response to care for each client shall be sent to the Physician...” 3. During an interview with the Administrator and Agency Supervisor on 4/9/25 at 11:00 AM, both stated that the clinical record should contain documentation of the follow up and information related to the referral to the above-mentioned program and external organizations for the recommended services. During the same interview, the above finding was confirmed.”