Life Source Home Health

“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 record review and interviews, the agency failed to encode and electronically transmit each completed OASIS (Outcome and Assessment Information Set) as evidenced by failing to ensure the agency successfully completed and transmitted OASIS data within 30 days of completion of the assessment of the beneficiary for 1 (R11) of 8 (#3, R8, R9, R10, R11, R12, R13, and R14) OASIS data records reviewed dated from 12/01/2024 through 12/19/2024. This deficient practice had the potential to affect all 42 patients listed on the agency’s current active census as of 12/16/2024. Findings: Review of the agency’s policy dated 11/2017, titled “Reporting of Oasis Information”, revealed, in part: Procedure 2. Agency must encode and have capability of transmitting OASIS data for each patient within thirty (30) days of completing any required OASIS data set collection. Review of the agency’s OASIS Final Validation Report with a submission date of 12/09/2024 revealed 8 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted on 12/18/2024 at 1:00 p.m. with S6OM. She stated she was responsible for submitting all Oasis data. S6OM confirmed all OASIS should be submitted within 30 days of the assessment completion date and were not. An interview was conducted on 12/18/2024 at 1:05 p.m. with S2DON. S2DON confirmed all OASIS should be submitted within 30 days of the assessment completion date and were not.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record reviews and interview, the Home Health agency failed to ensure discharge orders were obtained from the physician and documented in the clinical record for 1 (#7) of 7 (#1, #2, #3, #4, #5, #6 and #7) patients’ records reviewed for verbal orders. This deficient practice had the potential to affect all 42 patients listed on the current active patient census as of 12/16/2024. Findings: Review of Patient #7’s clinical record revealed a SOC (Start of Care) date of 02/05/2024. Patient #7’s 485/Plan of Care (PoC) for the certification period 04/05/2024 through 06/03/2024 revealed the following physician’s orders, in part: Skilled Nurse: One time a week for 8 weeks effective 04/07/2024. Discharge when goals met. Review of Patient #7’s physician’s orders dated 04/27/2024 written by S5RN revealed the following: Skilled Nurse: Two times a week for three weeks, then one time a week for two weeks effective week of 04/29/2024. Further review revealed Patient #7 was discharged on 05/02/2024 by S5RN without documentation of a verbal discharge order by her physician, and without documentation goals were met. Review of personnel files revealed S5RN was no longer employed with the agency and was not available for interview. An interview was conducted on 12/19/2024 at 10:10 a.m. with S2DON. S2DON confirmed Patient #7’s was discharged on 05/02/2024 prior to completing PoC ordered services and without documentation nursing goals were met. S2DON stated a discharge verbal order should have been obtained and documented by S5RN for Patient #7 on or before 05/02/2024 and was not.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on record reviews and interviews, the Home Health agency failed to provide the patient and his/her caregiver written information regarding the patient’s medication schedule/instructions for 1 (#3) of 3 ( #1, #2, and #3) patients reviewed with home visits. This deficient practice had the potential to affect all 42 patients listed on the agency’s current active census as of 12/16/2024. Findings: Review of the agency’s policy dated 11/2017, titled “Medication Reconciliation”, revealed in part: Procedure 1. At time of admission, the admitting Registered Nurse (RN), Physical Therapist (PT), or SLP (Speech Language Pathologist) will create and document a complete list of medications the patient is taking at home, including dose, route, frequency, and duration. 2. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication and reviewed each visit. Review of Patient #3’s Clinical Record revealed she was admitted to the agency on 11/14/2024. Further review of Patient #3’s 485/PoC (Plan of Care) for Certification period 11/14/2024 through 01/12/2025 revealed she was prescribed the following medications: Bupropion HCL 75mg (milligram) 1 tablet by mouth twice daily Eliquis 2.5mg 1 tablet by mouth twice daily Oxybutynin Chloride ER 15mg tablet by mouth daily Donepezil HCL 10mg 1 tablet by mouth every evening Duloxetine HCL 30mg 1 capsule by mouth daily Duloxetine HCL 60mg 1 capsule by mouth daily Pantoprazole Sodium 40mg 1 tablet by mouth daily Levothyroxine Sodium 25mcg (microgram) 1 tablet by mouth daily Diltiazem HCL 90mg 1 tablet by mouth twice daily Carvedilol 3.25mg 1 tablet by mouth twice daily Lyrica 100mg 1 capsule by mouth twice daily During a home visit on 12/16/2024 at 2:05 p.m., an interview was conducted with Patient #3; S4PT was present. Patient #3 stated her daughter assisted her with her medications. Review of Patient #3’s home folder revealed there was no medication list/profile available in the folder. An interview was conducted on 12/16/2024 at 2:20 p.m. with S4PT. S4PT confirmed Patient #3’s home folder did not contain a current medication list/profile and should have. An interview was conducted on 12/16/2024 at 3:08 p.m. with S2DON. The home visit with Patient #3 was discussed. S2DON confirmed Patient #3’s home folder should have had an accurate medication list/profile available for the patient/caregiver.”