Pulse Home Health Care

“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 ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the CMS system within 30 days of completion. This deficient practice had the potential to affect all 470 patients, according to the agency’s current active census reported on 02/24/2025. Findings: Review of the agency’s undated policy titled, “Reporting of Oasis Information” revealed the following, in part: Procedure: 1. 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. Agency staff will ensure the accuracy of OASIS data reflects the patient’s status at time of assessment and data collection. Review of the agency’s OASIS Final Validation Report with a submission date of 01/02/2025 revealed 33 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. Review of the agency’s OASIS Final Validation Report with a submission date of 01/03/2025 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. Review of the agency’s OASIS Final Validation Report with a submission date of 01/13/2025 revealed 27 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. Review of the agency’s OASIS Final Validation Report with a submission date of 01/28/2025 revealed 20 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. Review of the agency’s OASIS Final Validation Report with a submission date of 02/04/2025 revealed 20 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. Review of the agency’s OASIS Final Validation Report with a submission date of 02/17/2025 revealed 13 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. Review of the agency’s OASIS Final Validation Report with a submission date of 02/17/2025 revealed 52 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 with S4ADON on 02/26/2025 at 3:30 p.m. S4ADON stated she was responsible for all OASIS submissions. S4ADON confirmed the above records were submitted late. S4ADON stated OASIS Assessments should have been submitted within 30 days of completion and were not. An interview was conducted with S1ADM on 02/26/2025 at 3:35 p.m. S1ADM confirmed the above records were submitted late. S1ADM confirmed OASIS Assessments should be submitted within 30 days of completion and were not.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record reviews, observations, and interviews, the agency failed to maintain an accurate medication profile for 1 (#4) of 7 (#1, #2, #3, #4, #5, #6, and #7) sampled patients reviewed who received home visits. This deficient practice had the potential to affect all 470 patients, according to the agency’s current active census reported on 02/24/2025. Findings: Review of the agency’s undated policy titled “Medication Reconciliation” revealed, in part: Procedure: Medications ordered while 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. Clinicians will assess patient’s home medications on an ongoing basis. Review of Patient #4’s clinical record revealed a start of care date of 02/21/2025. The patient’s primary diagnosis was Other Generalized Epilepsy, Not Intractable, without Status Epilepticus. A review of the Home Health Certification and Plan of Care/485 for the Certification Period of 02/21/2025 through 04/21/2025 revealed orders which included Skilled Nurse 1w1, 2w1, 1w5, Physical Therapy 1w4, and Occupational Therapy 1w1, 2w2. Review of the agency’s current medication profile for Patient #4 dated 02/24/2025 revealed the following, in part: Plaquenil (Hydroxychloroquine) 200mg 1 tablet twice daily. Oxybutynin Chloride 5mg 1 tablet daily. Pilocarpine HCL 5mg tablet twice daily. Omeprazole 40mg capsule daily. Gabapentin 800mg (0.5 tab) half-tablet three times daily. On 02/25/2025 at 10:00 a.m., a home visit was conducted in the home of Patient #4 with S3OT. Review of the patient’s current medication profile list provided by the agency was reviewed with S3OT and Patient #4. Patient #4 stated she managed her own medications and verified she took the following medications: 1. Zolpidem 5 milligrams (mg) 1 tablet at bedtime as needed for insomnia. This medication was not listed on the patient’s current medication profile list provided by the agency. 2. Pravastatin 40mg 1 tablet by mouth daily. This medication was not listed on the patient’s current medication profile list provided by the agency. 3. Gabapentin 800mg 1 tablet by mouth three times daily. A bottle of the medication with a fill date of 09/24/2024 was observed in the home, instructions stated one-half (0.5) tablet by mouth three times daily. 4. Oxybutynin Chloride 5 mg 1 tablet by mouth every morning and evening. A bottle of the medication with a fill date of 01/23/2025 was observed in the home, instruction stated one tablet by mouth daily. An interview was conducted with Patient #4 on 02/25/2025 at 10:45 a.m. Patient #4 reported she no longer took the following medications: Plaquenil (Hydroxychloroquine) 200mg 1 tablet twice daily. Pilocarpine HCL 5mg tablet twice daily. Omeprazole 40mg capsule daily. An interview with S3OT was conducted on 02/25/2025 at 11:00 a.m. S3OT verified Patient #4’s agency and home medication profile lists had not been updated to reflect her current medications. An interview was conducted with S2DON on 02/27/2025 at 1:40 p.m. S2DON was made aware of the medication discrepancies found during the home visit with Patient #4. S2DON verified Patient #4’s agency and home medication profile lists were not current and should have been. An interview was conducted with S1ADM on 02/27/2025 at 1:43 p.m. S1ADM confirmed Patient #4’s agency and home medication profile lists should have accurately reflected the medications Patient #4 was currently prescribed and did not.”