Egan-Ochsner Home Health Northshore

“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 Centers for Medicare and Medicaid Services (CMS) system within 30 days of completion. This deficient practice had the potential to affect all 243 patients according to the agency’s active census on 04/07/2025. Findings: Review of the agency’s OASIS Agency Final Validation Report with a submission date of 03/11/2025 revealed 135 records were processed with 3 records 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 Agency Final Validation Report with a submission date of 03/19/2025 revealed 58 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 Agency Final Validation Report with a submission date of 03/25/2025 revealed 89 records were processed with 3 records 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 S2BM on 04/08/2025 at 11:10 a.m. She stated she was responsible for reviewing all Oasis Validation Reports to ensure they were submitted timely. She confirmed the above late submissions should have been submitted within 30 days of completion and were not. An interview was conducted with S1ED on 04/10/2025 at 2:00 p.m. S1ED confirmed the above records were submitted late. S1ED stated all 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 7 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 243 patients, according to the agency’s current active census reported on 04/07/2025. Findings: Review of the agency’s policy titled “Monitoring Medications,” with revision date of 07/01/2024, revealed, in part: Policy: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessment. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. The physician is contacted immediately if any discrepancies between agency information and patient medications are found. Procedure: 2. All clinicians participating in the patient’s care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care. b. The Physician will be notified of discrepancies and documentation of notification must be evident in the medical record. Patient #1 Review of Patient #1’s clinical record revealed a Start of Care (SOC) date of 02/20/2025. The patient’s primary diagnosis was Venous Insufficiency (Chronic) (Peripheral). A review of the Home Health Certification and Plan of Care (PoC) for the Certification Period of 02/20/2025 through 04/20/2025 revealed orders, which included: Skilled Nurse 1 time a week for 1 week then 3 times a week for 8 weeks. Physical Therapy 1 time a week for 4 weeks. Occupational Therapy 1 time a week for 1 week then 2 times a week for 2 weeks. Review of the agency’s current medication profile for Patient #1 dated 04/07/2025 revealed the following, in part: Docusate Sodium 100 milligram (mg) 1 tablet by mouth daily. Insulin Glargine 100units/milliliter (ml) 10 units subcutaneous at bedtime. Metoprolol Succinate ER (extended release) 25mg 1 tablet by mouth daily. On 04/07/2025 at 10:45 a.m., a home visit was conducted in the home of Patient #1 with S5LPN. Patient #1’s current medication profile list provided by the agency was reviewed with S5LPN, Patient #1 and his daughter. Patient #1 stated his daughter managed his medications and verified the following: 1. Docusate Sodium 100mg daily. Patient #1 stated he was taking daily as needed for constipation. 2. Insulin Glargine 100units/ml 10 units subcutaneous at bedtime. This medication was on the medication profile and Patient #1 stated he was not taking this medication. 3. Metoprolol Succinate ER 25mg 1 tablet by mouth daily. This medication was on the medication profile and Patient #1 stated he was not taking this medication. 4. Oxycodone 5mg/325mg 1 tablet by mouth every 4 hours as needed for pain. A prefilled blister pack of this medication was observed in the home with a fill date of 12/31/2024. This medication was not on the medication profile and Patient #1 stated he was taking this medication as needed. 5. Vitamin D3 50,000 units by mouth weekly. A package of Vitamin D3 50,000 unit capsules with a fill date of 02/24/2025 was observed in the home. This medication was not on the medication profile and Patient #1 stated he was taking this medication. 6. Vitamin D2 1000 international units (IU) by mouth daily as needed for cold symptoms. This medication was not on the medication profile and Patient #1’s daughter stated he was taking this medication as needed. 7. Furosemide 40mg 1 tablet by mouth daily. A bottle of the medication with a fill date of 02/16/2025 was observed in the home, instructions stated one tablet by mouth once daily. This medication was not on the medication profile and Patient #1 stated he was taking this medication. An interview was conducted with S5LPN on 04/07/2025 at 11:30 a.m. S5LPN verified the above medication discrepancies. S5LPN confirmed Patient #1’s agency and home medication profile list had not been updated to reflect his current medications. Patient #2 Review of Patient #2’s clinical record revealed a Start of Care (SOC) date of 03/01/2025. The patient’s primary diagnosis was Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 Unspecified Chronic Kidney Disease. A review of the Home Health Certification and Plan of Care (PoC) for the Certification Period of 03/01/2025 through 04/29/2025 revealed orders, which included: Skilled Nurse 1 time a week for 10 weeks and 2 as needed visits for cardiac complications. Review of the agency’s current medication profile for Patient #2 dated 04/07/2025 revealed the following, in part: Berberine ES-5-200 mg 2 capsules by mouth daily. Dandelion Root 1 tablet by mouth daily. Fish Oil 1000mg 1 capsule by mouth daily. Ketoconazole 2% shampoo topical weekly. Liver-Kidney Cleanser capsule 1 capsule by mouth daily. Vitamin B-Complex-Vitamin C-Folic Acid-400mcg tablet 1 tablet by mouth daily. On 04/08/2025 at 8:30 a.m., a home visit was conducted in the home of Patient #2 with S3RN. Patient #2’s current medication profile list provided by the agency was reviewed with S3RN and Patient #2. Patient #2 stated she managed her own medications and verified the following: 1. Prednisolone 1% eye drops 1 drop into right eye three times daily. This medication was not on the medication profile and Patient #2 stated she was taking this medication. 2. Ilevro eye drops, 1 drop into right eye daily. This medication was not on the medication profile and Patient #2 stated she was taking this medication. 3. Metoprolol Succinate ER 25mg 1 tablet by mouth daily. A bottle of this medication, with fill date of 03/19/2025, was observed in the home. This medication was not on the medication profile and Patient #2 stated she was taking this medication. 4. Blood Builder 1 tablet by mouth daily. A bottle of this over-the-counter (OTC) medication was observed in the home. This medication was not on the medication profile and Patient #2 stated she was taking this medication. 5. Berberine ES-5-200 capsule by mouth daily. This medication was on the medication profile and Patient #2 stated she was not taking this medication. 6. Dandelion Root 1 tablet by mouth daily. This medication was on the medication profile and Patient #2 stated she was not taking this medication. 7. Fish Oil 1000mg 1 capsule by mouth daily. This medication was on the medication profile and Patient #2 stated she was not taking this medication. 8. Ketonazole 2% shampoo topical weekly. This medication was on the medication profile and Patient #2 stated she was not taking this medication. 9. Liver-Kidney Cleanser Capsule 1 capsule by mouth daily. This medication was on the medication profile and Patient #2 stated she was not taking this medication. 10. Vitamin B-Complex-Vitamin C-Folic Acid-400mcg tablet 1 tablet by mouth daily. This medication was on the medication profile and Patient #2 stated she was not taking this medication. 11. Entresto 49mg-51mg 1 tablet by mouth every 12 hours. This medication was not on the medication profile and Patient #2 stated she was taking this medication. 12. Zyrtec 10mg 1 tablet by mouth daily. This medication was not on the medication profile and Patient #2 stated she was taking this medication. On 04/08/2025 at 9:45 a.m. an interview was conducted with S3RN. S3RN verified the above discrepancies and confirmed Patient #2’s agency and home medication profile list had not been updated to reflect his current medications. Patient #3 Review of Patient #3’s clinical record revealed a Start of Care (SOC) date of 04/01/2025. The patient’s primary diagnosis was Aftercare Following Joint Replacement Surgery. A review of the Home Health Certification and Plan of Care (PoC) for the Certification Period of 04/01/2025 through 05/30/2025 revealed orders which included: Skilled Nurse 3 times a week for 1 week, then 1 time a week for 2 weeks. Physical Therapy 3 times a week for 2 weeks. Review of the agency’s current medication profile for Patient #3 dated 04/07/2025 revealed the following, in part: Allegra Allergy 180mg 1 tablet by mouth daily. Oxycodone 10mg 1 tablet by mouth as needed. On 04/08/2025 at 2:00 p.m., a home visit was conducted in the home of Patient #3 with S4RN and Patient #3’s spouse. Patient #3’s current medication profile list provided by the agency was reviewed with S4RN and Patient #3. Patient #3 stated he and his spouse managed his medications and verified the following: 1. Allegra Allergy 180mg 1 tablet by mouth daily. Patient #3 stated he was taking this medication as needed for allergies. 2. Oxycodone 10mg 1 tablet by mouth as needed. This medication was on the medication profile and Patient #3 stated he was not taking this medication. 3. Miralax 17gram (gm) 1 capful in 8 ounces of liquid by mouth daily. This medication was not on the medication profile and Patient #3 and spouse stated he was taking this medication. An interview was conducted with S4RN on 04/08/2025 at 2:15 p.m. S4RN verified the above discrepancies and confirmed Patient #3’s agency and home medication profile list had not been updated to reflect his current medications. Patient #4 Review of Patient #4’s clinical record revealed a Start of Care (SOC) date of 01/02/2025. The patient’s primary diagnosis was Acute Embolism and Thrombosis Unspecified Deep Veins of Right Distal Lower Extremity. A review of the Home Health Certification and Plan of Care (PoC) for the Certification Period of 03/03/2025 through 05/01/2025 revealed orders which included: Skilled Nurse 2 times a week for 1 week, then 1 time a week for 8 weeks, and 2 as needed. Physical Therapy 2 times a week for 5 weeks. Occupational Therapy 2 times a week for 3 weeks. Review of the agency’s current medication profile for Patient #4 dated 04/07/2025 revealed the following, in part: Bupropion HCL SR (slow release) 150mg 3 tablets by mouth daily. Cozaar 50mg 1 tablet by mouth daily. Warfarin 5mg tablet by mouth as instructed daily by Coumadin Clinic. On 04/09/2025 at 8:30 a.m., a home visit was conducted in the home of Patient #4 with S6PT and Patient #4’s spouse. Patient #4’s current medication profile list provided by the agency was reviewed with S6PT and Patient #4. Patient #4 stated she and her spouse managed her medications and verified the following: 1. Bupropion HCL SR 150mg 1 tablet by mouth daily. This medication was on the medication profile and Patient #4 stated she was not taking this medication. 2. Cozaar 50mg tablet by mouth daily. This medication was on the medication profile and Patient #4 stated she was not taking this medication. 3. Magnesium Oxide 400mg 1 tablet by mouth daily. This medication was on the medication profile and Patient #4 stated she was not taking this medication. 4. Warfarin 5mg 1 tablet by mouth as instructed daily by Coumadin Clinic. The medication profile had Warfarin 5mg listed twice. Patient #4 stated she was taking Warfarin 5mg daily. 5. Pregabalin 75mg 1 capsule by mouth twice daily. A bottle of this medication, with fill date of 04/03/2025, was observed in the home. This medication was not on the medication profile and Patient #4 stated she was taking this medication. 6. Methocarbamol 750mg 1 tablet by mouth four times a day as needed for spasms. A bottle of this medication, with fill date of 05/23/2024, was observed in the home. This medication was not on the medication profile and Patient #4 stated she was taking this medication. 7. Potassium Chloride 20 milliequivalent (meq) 1 tablet by mouth daily. A bottle of this medication, with fill date of 09/24/2024, was observed in the home. This medication was not on the medication profile and Patient #4 stated she was taking this medication. 8. Novolog 100units/ml 3 ml Flex pen 26 units with 2 additional units for every 50 mg/deciliter (dl) blood glucose level above 200. This medication was not on the medication profile and Patient #4 stated she was taking this medication. 9. Verapamil ER 240mg 1 tablet by mouth at bedtime. A bottle of this medication, with fill date of 09/24/2024, was observed in the home. This medication was not on the medication profile and Patient #4 stated she was taking this medication. An interview was conducted with S6PT on 04/09/2025 at 8:55 a.m. S6PT verified the above discrepancies and confirmed Patient #4’s agency and home medication profile list had not been updated to reflect her current medications. Patient #5 Review of Patient #4’s clinical record revealed a Start of Care (SOC) date of 02/25/2025. The patient’s primary diagnosis was Hemiplegia Following Cerebral Infarction Affecting Right Dominant Side. A review of the Home Health Certification and Plan of Care (PoC) for the Certification Period of 02/25/2025 through 04/25/2025 revealed orders, which included: Physical Therapy 2 times a week for 1 week, 1 time a week for 1 week, 2 times a week for 1 week, and 1 time a week for 1 week. On 04/09/2025 at 9:30 a.m., a home visit was conducted in the home of Patient #5 with S8PTA and the QIDP (Qualified Intellectual Disability Professional) from the group home. Patient #5’s current medication profile list provided by the agency was reviewed with S8PTA and Patient #5’s QIDP. Patient #5’s QIDP stated the group home managed her medications and verified the following: 1. Clotrimazole Cream 1% topical twice daily as needed. This medication was not on the medication profile and Patient #5’s QIDP stated she was taking this medication. 2. Mupirocin Ointment 2% topical 3 times a day as needed. This medication was not on the medication profile and Patient #5’s QIDP stated she was taking this medication. 3. Nystatin 10,000 units topical to affected area after each meal and at bedtime as needed. This medication was not on the medication profile and Patient #5’s QIDP stated she was taking this medication. 4. Triamcinolone 1% topical to affected area after each meal and at bedtime as needed. This medication was not on the medication profile and Patient #5’s QIDP stated she was taking this medication. 5. ACT Mouthwash 15milliliters (ml) by mouth swish and spit every morning and evening. This medication was not on the medication profile and Patient #5’s QIDP stated she was taking this medication. 6. Lasix 20mg one-half tablet by mouth daily as needed for weight gain >3 pounds or more. This medication was not on the medication profile and Patient #5’s QIDP stated she was taking this medication. 7. Loratadine 10mg 1 tablet by mouth daily as needed for allergies. This medication was not on the medication profile and Patient #5’s QIDP stated she was taking this medication. An interview was conducted with S8PTA on 04/09/2025 at 9:50 a.m. S8PTA verified the above discrepancies and confirmed Patient #5’s agency and home medication profile list had not been updated to reflect her current medications. Patient #6 Review of Patient #6’s clinical record revealed a Start of Care (SOC) date of 03/10/2025. The patient’s primary diagnosis was Unspecified Displaced Fracture of Surgical Neck of Left Humerus, Subsequent Encounter for Fracture with Routine Healing. A review of the Home Health Certification and Plan of Care (PoC) for the Certification Period of 03/10/2025 through 05/08/2025 revealed orders which included: Skilled Nurse 1 time a week for 9 weeks, and 2 visits as needed. Physical Therapy 3 times a week for 1 week, and 2 times a week for 2 weeks. Occupational Therapy 2 times a week for 1 week, and 1 time a week for 4 weeks. Speech Therapy 1 time a week for 4 weeks. Review of the agency’s current medication profile for Patient #4 dated 04/07/2025 revealed the following, in part: Glipizide 2.5mg 1 tablet by mouth daily. Wellbutrin SR 100mg 1 tablet by mouth daily. On 04/09/2025 at 11:15 a.m., a home visit was conducted in the home of Patient #6 with S9ST. Patient #6’s current medication profile list provided by the agency was reviewed with S9ST and Patient #6. Patient #6 stated her daughter managed her medications and verified the following: 1. Glipizide 10mg 1 tablet by mouth daily. A bottle of this medication, with fill date of 03/24/2025, was observed in the home. This medication was not on the medication profile and Patient #6 stated she was taking this medication. 2. Wellbutrin SR 75mg 1 tablet by mouth every morning. A bottle of this medication, with fill date of 12/13/2024, was observed in the home. This medication was not on the medication profile and Patient #6 reported she was taking this medication. 3. Iron 65mg 1 tablet by mouth daily. An OTC bottle of this medication was in the home. This medication was not on the medication profile and Patient #6 stated she was taking this medication. 4. Oxycodone 7.5mg/325mg 1 tablet by mouth every 6 hours as needed for pain. A bottle of this medication was in the home. This medication was not on the medication profile and Patient #6 stated she was taking this medication. 5. Aspirin EC 81mg 1 tablet by mouth daily. A bottle of this medication, with fill date of 03/12/2025, was observed in the home. This medication was not on the medication profile and Patient #6 stated she was taking this medication, which was on hold for surgery currently. An interview was conducted with S9ST on 04/09/2025 at 11:45 a.m. S9ST verified the above discrepancies and confirmed Patient #6’s agency and home medication profile list had not been updated to reflect her current medications. Patient #7 Review of Patient #7’s clinical record revealed a Start of Care (SOC) date of 03/25/2025. The patient’s primary diagnosis was Unspecified Fracture Upper End of Left Humerus, Subsequent Encounter for Fracture with Routine Healing. A review of the Home Health Certification and Plan of Care (PoC) for the Certification Period of 03/25/2025 through 05/23/2025 revealed orders which included: Skilled Nursing 1 time a week for 9 weeks and 2 visits as needed for complications related to fracture. Physical Therapy 2 times a week for 3 weeks, 1 time a week for 1 week. Occupational Therapy 1 time a week for 5 weeks. Review of the agency’s current medication profile for Patient #7 dated 04/08/2025 revealed the following in part: Vitamin D2 1,250 mcg (50,000 unit) 1 capsule by mouth weekly. On 04/09/2025 at 1:00 p.m., a home visit was conducted in the home of Patient #7 with S7OT. Patient #7’s current medication profile list provided by the agency was reviewed with S7OT. Patient #7 stated she managed her own medications and verified the following: 1. Vitamin D3 13,000 IU 1 capsule by mouth weekly on Wednesdays. A sample package of this medication was observed in the home. This medication was not on the medication profile and Patient #7 stated she was taking this medication. 2. Meloxicam 15mg 1 tablet by mouth every day. A bottle of this medication, with fill date of 02/05/2025, with instructions to take 1 tablet by mouth once daily, was observed in the home. This medication was not on the medication profile and Patient #7 stated she was taking this medication daily as needed. An interview was conducted with S7OT on 04/09/2025 at 1:15 p.m. S7OT verified the above discrepancies and confirmed Patient #7’s agency and home medication profile list had not been updated to reflect her current medications. An interview was conducted with S1ED on 04/10/2025 at 2:00 p.m. S1ED was made aware of the medication discrepancies found during the home visits above. S1ED confirmed Patients #1-#7’s agency and home medication profile lists should have accurately reflected the medications currently prescribed and did not.”

“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 interviews, the agency failed to provide skilled professional services according to the patient’s Plan of Care (PoC) for 1 (#6) of 17 (#1-#17) sampled patients reviewed. This deficient practice had the potential to affect all 243 patients according to the agency’s active census reported on 04/07/2025. Findings: Review of the agency’s policy titled, “Coordination of Care, From Admit Through Discharge,” with revision date of 09/02/2024, revealed in part: Procedure: 5. Coordination of Care among disciplines and between in-person and virtual clinicians. Patient care is coordinated among various disciplines through care planning processes to ensure continuity of care from admission to discharge. This includes: i. All clinicians will report within 1 business day to the Patient Care Manager or Clinical Director by fax, telephone, in person at the agency, or through coordination notes. Report will include: Missed visits and changes to scheduled visits. a. Reason for missed visit b. Changes to patient schedule Review of Patient #6’s Plan of Care (PoC) for the Certification period dated 03/10/2025 through 05/08/2025 revealed a primary diagnosis of Unspecified Displaced Fracture of Surgical Neck of Left Humerus. Further review of the plan of care revealed the following orders, in part: Physical Therapy 3 times a week for 1 week. Occupational Therapy 2 times a week for 1 week. Review of the agency’s visit summary report for Patient #6 revealed the following: Physical Therapy (PT) visits were completed on 03/10/2025 and 03/12/2025. An Occupational Therapy (OT) visit was completed on 03/11/2025. Further review revealed there was no missed visit documentation available for review for Patient #6’s missed PT and OT visit the week of 03/10/2025. A phone interview was conducted with S11PT on 04/10/2025 at 3:20 p.m. S11PT verified a PT visit was not completed on 03/15/2025. She stated a PT missed visit on 03/15/2025 should have been documented. She verified Patient #6’s ordered PT frequency was 3 times a week, and only 2 visits had been completed the week of 03/10/2025. S11PT confirmed all patients should receive services per their ordered PoC, and Patient #6 did not. A phone interview was conducted with S7OT on 04/10/2025 at 3:30 p.m. S7OT verified an OT visit was not completed on 03/15/2025. She stated an OT missed visit on 03/15/2025 should have been documented. She verified Patient #6’s ordered OT frequency was 2 times a week, and only 1 visit had been completed the week of 03/10/2025. S7OT confirmed all patients should receive services per their ordered PoC, and Patient #6 did not. An interview was conducted with S1ED on 04/10/2025 at 3:10 p.m. S1ED verified Patient #6’s visit summary for PT and OT. S1ED confirmed Patient #6 did not receive all ordered PT and OT visits the week of 03/10/2025 per the PoC and should have. S1ED stated the clinicians should have documented a missed visit coordination note when services were not provided per Patient #6’s PoC and did not.”