Smh-Ochsner Home Health of Slidell

“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 interview, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of completion. This deficient practice had the potential to affect all 394 patients according to the agency’s active census. Findings: Review of the agency’s revised policy dated 10/01/2025 and titled “OASIS Data Capture, Transmission, Verification, Display and Reports” revealed, in part: Procedure 2. Transmittal of OASIS data a. At least monthly, Agency will electronically transmit accurate, completed, encoded, and locked OASIS data to the state agency. All OASIS assessments completed must be transmitted within thirty (30) days of the completion (M0090) date. Review of the agency’s OASIS Final Validation Report dated 04/07/2026 revealed 133 total records were submitted with 1 record submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 04/08/2026 revealed 18 total records were submitted with 1 record submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 04/21/2026 revealed 113 total records were submitted with 1 record submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 05/05/2026 revealed 136 total records were submitted with 2 records submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 05/20/2026 revealed 161 total records were submitted with 1 record submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 05/26/2026 revealed 105 total records were submitted with 2 records submitted greater than 30 days of the completion date. Review of the agency’s OASIS Final Validation Report dated 06/02/2026 revealed 119 total records were submitted with 3 records submitted greater than 30 days of the completion date. An interview was conducted with S1ED on 06/22/2026 at 1:05 p.m. S1ED stated all OASIS assessments should be submitted within 30 days of the completion date. The above OASIS Final Validation Reports and the Agency Oasis Data Error Report dated 04/01/2026 through 06/18/2026 were reviewed with S1ED. S1ED confirmed the above OASIS assessments were submitted greater than 30 days of the completion date.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on record reviews and interview, the agency failed to have the Plan of Care (POC) reviewed and revised by the physician every 60 days, beginning with the SOC (Start of Care) date for 3 (#4, #13, and #14) of 17 sampled patients reviewed. Patient #14 Review of Patient #14’s clinical record revealed a SOC date of 01/07/2026. Review of Patient #14’s POC for the certification period dated 01/07/2026 through 03/07/2026 revealed the POC was not reviewed, revised, or approved by Patient #14’s physician every 60 days. Findings: Review of the agency’s revised policy dated 03/01/2026, and titled “Plan of Care (POC)” revealed, in part: Purpose To assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure the physician/authorized practitioner’s orders are followed. Procedure 1. A POC is developed for all patients and updated no less than every 60 days. Patient #4 Review of Patient #4’s clinical record revealed a SOC date of 01/21/2026. Review of Patient #4’s POC for the certification period dated 03/22/2026 through 05/20/2026 revealed the POC was not reviewed, revised, or approved by Patient #4’s physician every 60 days. Patient #13 Review of Patient #13’s clinical record revealed a SOC date of 06/04/2025. Review of Patient #13’s POC for the certification period dated 06/04/2025 through 08/02/2025 revealed the POC was not reviewed, revised, or approved by Patient #13’s physician every 60 days. An interview was conducted with S1ED on 06/15/2026 at 1:32 p.m. S1ED reviewed the above mentioned POC’s for Patients #4, #13 and #14, and confirmed their POC’s had not been reviewed, revised, or approved by their physicians every 60 days and should have been.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record reviews and interview, the agency failed to provide services as ordered by the physician in the Plan of Care (POC) for 1 (#11) of 17 sampled patients reviewed. Findings: Review of the facility’s revised policy dated 03/01/2026 and titled “Plan of Care” revealed, in part: Policy Each patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. Procedure 2. The POC includes: b. Types, frequency, and duration of services required that may include virtual services. n. All patient care orders. Review of Patient #11’s clinical record revealed she began receiving services from the agency on 05/13/2026, with diagnoses, which included in part, Sepsis Due to Escherichia Coli, Tubulo-Interstitial Nephritis, Pneumonitis Due to Inhalation of Food and Vomit, and History of Falling. Review of Patient #11’s POC for the certification period dated 05/13/2026 through 07/11/2026, reviewed and signed by Patient #11’s physician on 06/10/2026, revealed in part: Physical Therapy to evaluate/ assess and develop a Physical Therapy Plan of Care that will be approved by the physician prior to implementation. Occupational Therapy to evaluate/assess and develop an Occupational Therapy Plan of Care that will be approved by the physician prior to implementation. Supporting Documentation for Home Health Eligibility: The patient has a normal inability to leave the home and when leaving the home, requires considerable and taxing effort as evidenced by: Easily fatigued, poor respiratory status, unsteady gait, physical limitation and/or paralysis impacting mobility, ability, and effort to leave home, weakness in lower extremities causing balance or gait disturbances, and/or falls. Review of Patient #11’s Start of Care (SOC) clinical summary completed by S2RN on 05/13/2026, revealed, in part: In addition to skilled care the patient needs the following: PT, OT evaluations for safety and strengthening exercises. Review of Patient #11’s agency calendar of completed visits for Physical Therapy (PT) and Occupational Therapy (OT) revealed PT and OT services were not provided, as ordered by the physician, on or after 06/10/2026. An interview was conducted with S1ED on 06/17/2026 at 2:00 p.m. S1ED stated all home health services should be provided according to the clients’ physician approved POC. S1ED reviewed Patient #11’s POC for the certification period dated 05/13/2026 through 07/11/2026. S1ED confirmed there was no documented evidence PT and OT services were provided as ordered by the physician, on or after 06/10/2026 and should have been.”