Audubon 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 interview, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the CMS (Centers for Medicare and Medicaid Services) system within 30 days of completion. Review of the agency’s policy titled, “OASIS Data Transmission” with a revision date of April 2018 revealed the following, in part: Purpose: To outline the OASIS data transmission requirements. Policy: The organization will adhere to all OASIS data transmission requirements as outlined in the Medicare Conditions of Participation, Reporting of OASIS Information. Procedure: 1. The organization will encode and transmit completed OASIS data for each applicable patient within thirty days of the M0090 date, date assessment completed. Review of the agency’s OASIS Final Validation Report with a submission date of 05/18/2024 revealed 169 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 05/24/2024 revealed 140 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 06/04/2024 revealed 142 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 07/12/2024 revealed 146 records were processed with 2 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 Final Validation Report with a submission date of 07/26/2024 revealed 194 records were processed with 2 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 S2ADON on 08/08/2024 at 10:00 a.m. He confirmed the above records were submitted late. He stated OASIS Assessments should have been submitted within 30 days of completion.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interviews and record review, the agency failed to ensure Home Health Aide Supervisory visits were conducted every fourteen days for 1 (#5) of 3 (#4, #5, and #12) patients reviewed with Home Health Aide Services. Review of the agency’s policy Titled, “Home Health Aide Supervisory Visits” with a revision date of April 2018 revealed the following, in part: Purpose: To establish guidelines for the responsibilities and the frequency of supervisory visits for home health aide personnel. Policy: The registered nurse or other appropriate skilled professional that is familiar with the patient, the patient’s plan of care, and the written patient care instructions must conduct supervisory visits to the patient’s residence at regular intervals. Procedure: 1. The frequency of supervisory visits will be based upon the needs of the patients after the plan of care is established. They must be conducted no less frequently than every 14 days if the patient is receiving skilled services. Review of Patient #5’s Clinical Record revealed she began receiving services from the agency on 05/08/2024, had a current certification period of 07/07/2024 through 09/04/2024, and diagnoses, which included Hypertensive Heart Disease with Heart Failure, Encephalopathy, Spondylosis Without Myopathy or Radiculopathy – Lumbar Region, Other Cervical Disc Degeneration, and History of Falling. Review of Patient #5’s Physician Ordered discipline frequency revealed she received Home Health Aide visits twice weekly for three weeks and Occupational Therapy (OT) visits once weekly for three weeks. Review of Patient #5’s Home Health Aide visits revealed she had visits on 07/09/2024, 07/12/2024, 07/16/2024, 07/19/2024, 07/23/2024, and 07/26/2024. Review of Patient #5’s OT Visit Notes dated 07/23/2024 completed by S3OT revealed the following, in part: Were supervisory functions performed? – No Review of Patient #5’s Supervisory Visit Note signed by S3OT dated 07/23/2024 revealed it was blank. An interview was conducted with S3OT on 07/31/2024 at 1:13 p.m. S3OT confirmed she conducted Patient #5’s OT discharge assessment. S3OT stated she had never performed an aide supervisory visit for Patient #5. An interview was conducted with S1DON on 07/31/2024 at 1:18 p.m. S1DON reviewed Patient #5’s clinical record and confirmed an aide supervisory visit should have been conducted by S3OT on 07/23/2024. S1DON confirmed there was no documentation in Patient #5’s Clinical Record an aide supervisory visit was completed. S1DON confirmed Aide Supervisory Visits should have been conducted at least every fourteen days and were not.”