Midwest Healthcare Provider, 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 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 08/28/24. The report contained information that out of the 323 Agency’s OASIS assessment reports, 25 (7.74%) were submitted beyond the required time frame of 30 days. 2. During an interview with the Administrator and Agency Supervisor on 08/29/24 at 2:30 PM. The Administrator 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 record review and staff interview, it was determined in 2 of 7 (Pts. # 3 and 5) clinical records reviewed, patient care was not provided as ordered in the plan of care. Findings include: 1. Pt. #3 was admitted to Home Health Services on 02/16/24 with diagnoses of Type 2 Diabetes Mellitus without complications and Heart Failure, Unspecified. The clinical record was reviewed on 08/29/24. The clinical record contained a recertification POC dated 08/09/24, that required the SN to notify the physician of weight gain/loss greater than 5 lbs. The SN visit notes lacked the weight assessments after 08/07/24 (weeks #1 and #2). 2. Pt. #5 was admitted to Home Health Services on 06/01/23 with diagnoses of Bilateral Primary Osteoarthritis of Knee and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 08/29/24. The clinical record contained a recertification POC dated 05/26/24, that required the SN to notify the physician of pain greater than 7 and weight gain/loss greater than 5 lbs. The SN did not assess the pain or the weight on 06/14/24 (weeks #3) and 06/21/24 (week #4). 3. The findings were confirmed, during the interview with the Administrator and Agency Supervisor, on 08/29/24 between 11:00 am – 11:30 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 review and staff interview, it was determined in 2 of 7 (Pts. #5 and 7) clinical records reviewed, the clinical records were not accurate or completed as required. Findings include: 1.Pt. #5 was admitted to Home Health Services on 06/01/23 with diagnoses of Bilateral Primary Osteoarthritis of Knee and Type 2 Diabetes Mellitus without complications. The clinical record was reviewed on 08/29/24. The clinical record included the SN visit note dated 07/19/24 with a weight of 265 lbs. The SN assess the weight on 07/23/34 as 231 lbs (34 lbs difference). During the interview with the Agency Supervisor, it was stated this weight was not accurate, it was a documentation error. 2. Pt. #7 was admitted to Home Health Services on 06/22/23 with the diagnoses of Bilateral Primary Osteoarthritis of Knee. The complete clinical record was reviewed on 08/28/24. The clinical record included a POC dated 06/22/23 that lacked the signature of the physician. 3. The findings were confirmed, during the interview with the Administrator and Agency Supervisor, on 08/29/24 between 11:00 am – 11:30 am.”