Elara Caring

“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 275 patients according to the agency’s active census on 06/04/2025. Findings: Review of the agency’s policy dated 09/09/2020 titled “Encoding and Reporting Oasis Data” revealed, in part: 3. Procedures: 1. [Provider] will submit individual client assessment data within thirty (30) days of completing the comprehensive assessment. Review of the agency’s OASIS Agency Final Validation Report with a submission date of 05/06/2025 revealed 41 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 05/27/2025 revealed 36 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 Agency Final Validation Report with a submission date of 05/29/2025 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. An interview was conducted with S2DON on 06/09/2025 at 3:05 p.m. S2DON confirmed the above late submissions should have been submitted within 30 days of completion and were not. An interview was conducted with S1ADM on 06/09/2025 at 3:08 p.m. S1ADM confirmed the above records were submitted late. S1ADM 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 observations, record reviews and interviews, the agency failed to maintain an accurate medication profile for 1 (#5) 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 275 patients, according to the agency’s current active census reported on 06/04/2025. Findings: Review of the agency’s policy with revision date 12/12/2024 titled, “Medication Reconciliation, Review and Administration” revealed, in part: Procedures The Registered Nurse or Therapist will complete a patient medication report/profile for each patient at the time of admission. The report shall include all prescription and nonprescription drugs, including regularly scheduled medications, over the counter, herbal, nutritional supplements, and those taken as needed. The medication profile will be reviewed and updated as needed by all qualified clinicians (Registered Nurse, Licensed Practical Nurse, Physical Therapist, Occupational Therapist and Speech Therapist) to reflect current medication the patient is taking. Review of Patient #5’s clinical record revealed a Start of Care (SOC) date of 05/20/2025. The patient’s primary diagnosis was Acute Embolism and Thrombus Unspecified Deep Veins of Left Lower Extremity. A review of the Home Health Certification and Plan of Care (PoC) for the Certification Period of 05/20/2025 through 07/18/2025 revealed orders, which included: Skilled Nurse 2 times a week for 2 weeks, 1 time a week for 1 week, then 1 time a week every 2 weeks for 6 weeks. Physical Therapy 1 time a week for 1 week, 2 times a week for 2 weeks then 1 time a week for 1 week. 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 #5 dated 06/04/2025 revealed the following, in part: Acetaminophen 500 milligram (mg) 2 tablets=1000 mg by mouth three times daily as needed for mild to moderate pain. Atorvastatin 20mg 2 tablets=40mg by mouth daily. Culturelle 10 Billion Cell 1 capsule by mouth daily. Furosemide 20mg 1 tablet by mouth daily as needed for leg swelling. Melatonin 5mg tablet 1 tablet by mouth daily at bedtime. Olmesartan 20mg tablet 1 tablet by mouth daily as needed for Systolic Blood Pressure (SBP) greater than 130 and Diastolic Blood Pressure (DBP) greater than 90. An observation was made on 06/05/2025 at 12:30 p.m. when a home visit was conducted with Patient #5 and S7OT at a local assisted living facility (ALF). S7OT stated the facility’s medication nurse administered all of Patient #5’s medications. S7OT did not reconcile Patient #5’s current medications during the home visit observed, and confirmed medications should be reconciled every visit. Patient #5 confirmed the ALF medication nurse managed all of his current medications. S7OT then left the facility. A record review and interview were conducted on 06/05/2025 at 1:15 p.m. with Patient #5’s ALF nurse. Patient #5’s current medication profile list provided by the agency was reviewed and compared with the ALF’s medication list. The ALF nurse confirmed the following: 1. Acetaminophen 500mg tablets. This medication was on the agency’s medication profile and not on the ALF medication list. The ALF nurse stated Patient #5 was not taking this medication. 2. Atorvastatin 20mg 2 tablets. This medication was on the agency’s medication profile. The ALF nurse stated Patient #5 was taking 1 tablet daily. 3. Culturelle 10 Billion Cell capsule daily. This medication was on the agency’s medication profile. The ALF nurse stated Patient #5 was taking Complete Probiotic twice daily. 4. Furosemide 20mg tablet daily. This medication was not on the agency’s medication profile. The ALF nurse stated Patient #5 was taking Furosemide 20mg daily. 5. Melatonin 5mg tablet. This medication was on the agency’s medication profile and not on the ALF medication list. The ALF nurse stated Patient #5 was not taking this medication. 6. Olmesartan 20mg tablet daily. This medication was not on the agency’s medication profile. The ALF nurse stated Patient #5 was taking Olmesartan 20mg daily. An interview was conducted with S2DON on 06/09/2025 at 3:10 p.m. S2DON was notified of the medication discrepancies found during the home visit above. S2DON confirmed Patient #5’s agency medication profile list should have accurately reflected the medications currently prescribed and did not. An interview was conducted with S1ADM on 06/09/2025 at 3:12 p.m. S1ADM was notified of the medication discrepancies found during the home visit above. S1ADM confirmed Patient #5’s agency medication profile list should have accurately reflected the medications currently prescribed and did not.”

“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 interviews, 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 1 (#13) of 17 (#1-#17) sampled patients reviewed. This deficient practice had the potential to affect all 275 patients, according to the agency’s current active census reported on 06/04/2025. Findings: Review of the agency’s policy with a revision date of 03/04/2025 titled “Plan of Care and Coordination of Care” revealed in part: The patient’s individualized plan of care will be reviewed and revised by the physician or allowed practitioner who is responsible for the plan of care and the home health agency as frequently as the patient’s condition or needs requires, but no less frequently than once every 60 days, beginning with the start of care date or more frequently. Review of Patient #13’s Clinical Record revealed Patient #13’s SOC date was 07/27/2023. Review of the PoC for certification period 05/22/2024 through 07/20/2024 revealed the physician did not sign the PoC until 07/30/2024. An interview was conducted with S2DON on 06/09/2025 at 3:12 p.m. The above PoC for Patient #13 was reviewed. S2DON confirmed all PoC orders should be reviewed and signed by the physician within 60 days, and Patient #13’s was not. An interview was conducted with S1ADM on 06/09/2025 at 3:14 p.m. The above PoC for Patient #13 was reviewed. S1ADM confirmed all PoC orders should be reviewed and signed by the physician within 60 days, and Patient #13’s was 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 (#14) of 17 (#1-#17) sampled patients reviewed. This deficient practice had the potential to affect all 275 patients, according to the agency’s current active census reported on 06/04/2025. Findings: Review of the agency’s policy dated 03/04/2025 titled, “Plan of Care and Coordination of Care”, revealed in part: Procedures The plan of care will specify the care/services necessary to meet the patient-specific needs as identified in the comprehensive assessment. The plan of care will identify the responsible discipline(s), the amount, frequency, and duration of the disciplines for the patient. Care/services will be provided by the home health agency in accordance with the accepted standards of practice. Review of Patient #14’s Plan of Care (PoC) for the Certification period dated 02/22/2024 through 04/21/2024 revealed a primary diagnosis of Chronic Obstructive Pulmonary Disease, Unspecified. Further review of the plan of care revealed the following orders, in part: Physical Therapy 2 times a week for 2 weeks then 1 time a week for 1 week effective 02/25/2024. Review of the agency’s visit summary report for Patient #14 revealed Physical Therapy (PT) visits were completed on 02/26/2024, 03/05/2024, 03/07/2024 and 03/13/2024. Further review revealed there was no missed visit documentation available for review for Patient #14’s missed PT visit the week of 02/26/2024. An interview was conducted with S2DON on 06/09/2025 at 3:15 p.m. S2DON verified Patient #14’s visit summary for PT. S2DON confirmed Patient #14 did not receive all ordered PT visits the week of 02/26/2025 per the PoC and should have. An interview was conducted with S1ADM on 06/09/2025 at 3:17 p.m. S1ADM verified Patient #14’s visit summary for PT. S1ADM confirmed Patient #14 did not receive all ordered PT visits the week of 02/26/2024 per the PoC and should have. S1ADM stated the clinicians should have documented a missed visit coordination note when services were not provided per Patient #14’s PoC and did not.”