Caretenders

“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 document review and staff interview, the agency failed to electronically transmit completed Outcome and Assessment Information Set (OASIS-a group of standard data elements developed to enable systemic comparative measurements of home health care patient outcomes) assessments to the Centers for Medicare and Medicaid Services (CMS) system within the required 30 days of completing the assessments of the beneficiary. Findings include: Review of the agency policy entitled, OASIS Data Capture, Transmission, Verification, Display and Reports, revised 3/1/21, indicated the following: *Once an OASIS data set passes the OASIS edit check program, the OASIS data set will be reserved to prevent subsequent editing. The reserving mechanism ensures the stability of the patient assessment data at the time point of the assessment. The reserving mechanism prevents the override of current assessment information with future or past information without specific documentation as to why the assessment is being opened. All assessments will be reserved and transmitted within 30 days of M0090 (the last date that information used to complete the comprehensive assessment). Review of the Home Health Agency (HHA) Error Summary by Agency Report indicated the agency had 612 late OASIS Assessment submissions between 9/4/24 to 9/4/25, out of a total of 23726, which equaled to a 2.58% error rate. During an interview on 9/10/25 at 1:30 P.M., the Executive Director said the agency has a 2.58% error rate due to having difficulty working with providers to obtain needed information to compete the OASIS. He said it was a work in progress but could not provide any specific information.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, policy review and interview, the agency staff failed to ensure infection control guidelines were maintained during the home visit observations of wound care for three patients (#6, #7 and #12), out of a total sample of seven patient home visits. Findings include: 3. For Patient #12, LPN #1 failed to follow accepted standards of practice while performing wound care. Patient #12 was admitted to the agency in August 2025 and had a diagnosis of aftercare following joint replacement surgery. Review of a physician’s order, dated 9/10/25 at 8:38 A.M., indicated the following: -PICO (single-use negative pressure wound therapy system) dressing to be removed at home by visiting nurse on 9/10/25. -If there is no drainage, leave open to air. On 9/10/25 at 8:57 A.M., a home visit was conducted with LPN #1. At 9:13 A.M., LPN #1 removed the PICO dressing from Patient #12’s left knee and disposed of it. She then cleansed the wound with normal saline and 4x4 gauze pads. LPN #1 did not dispose of her gloves, perform hand hygiene, and don new gloves after removing the old dressing and prior to cleansing the wound. During an interview on 9/10/25 at 9:28 A.M., LPN #1 said she should have changed her gloves and performed hand hygiene in between but didn’t. During an interview on 9/10/25 at 1:20 P.M., the Director said after removing a soiled dressing, best practice is to dispose of the gloves, perform hand hygiene, and put on new gloves prior to cleansing a wound. Review of the agency policy entitled, Hand Hygiene, revised 5/1/19, indicated the following: *Staff are required to perform hand hygiene by handwashing with soap and water or using an alcohol-based hand sanitizer: a. Before direct contact with patients, b. Before performing an aseptic task (example, insertion of invasive devices, wound care). c. After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, wound dressings, or contaminated surfaces. d. If moving from a a contaminated body site to a clean body site during patient care. e. After contact with inanimate objects (including medical equipment but excluding the point of care device which is cleaned at the beginning and the end of the patient visit) in the vicinity of the patient. f. Before and after removal of personal protective equipment (PPE). g. At the conclusion of the visit after contact with a patient’s intact skin, (example, when taking vital signs, and lifting a patient). 1. For Patient #6, the staff failed to doff (remove) contaminated gloves and perform hand hygiene prior to opening a package of gauze. Patient #6 was admitted to the agency in April 2025 with a diagnosis of Alzheimer’s Disease. During an observation on 9/10/25 at 9:30 A.M., of a wound dressing change to the left lower extremity, Registered Nurse (RN) #1 removed the dressing, assessed the drainage on the dressing, and discarded the dressing. She then opened a package of sterile gauze with her soiled gloves, doffed her gloves, performed hand hygiene, donned (to put on) new gloves and utilized the gauze for the wound dressing procedure. During an interview on 9/10/25 at 10/20 A.M., RN #1 said she should have doffed her gloves, performed hand hygiene and donned new gloves after removing the soiled dressing, as required. 2. For Patient #7, the staff failed to a. perform hand hygiene after doffing soiled gloves and prior to donning new gloves and b. properly cleanse medical scissors (primarily used for cutting bandages) prior to use. Patient #7 was admitted to the agency in July 2023 with a diagnosis of chronic venous hypertension with ulcer of right extremity. During an observation on 9/10/25 at 11:00 A.M., of wound dressing changes to both lower extremities the surveyor observed the following: a. Licensed Practical Nurse (LPN) #2 did not cleanse her hands after doffing soiled gloves and prior to donning new gloves for three opportunities while performing left lower leg wound dressing change procedure. b. Prior to removing a Unna boot (a zinc-oxide impregnated dressing used for the lower leg to provide compression) from Patient #7’s left lower leg, LPN #2 applied hand sanitizer to the medical scissors and wiped the scissors with a blue chux (a single use underpad) and then with a white barrier pad. During an interview on 9/10/25 at 11:30 A.M., LPN #2 said she did not cleanse her hands prior to donning new gloves during the dressing change procedure and did not wipe the medical scissors appropriately, as required.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review, policy review and interview, the agency staff failed to ensure clinical documentation was complete and appropriately authenticated and dated in accordance with currently accepted standards of practice for five patients (#2, #5, #6, #7 and #17), out of a total sample of 17 patients. Findings include: 4. Patient #7 was admitted to the agency in July 2023 with a diagnosis of chronic venous hypertension with ulcer of right lower extremity. Review of the Physician ordered Plan of Care for certification period 711/25 through 9/8/25 indicated the following: -SN visit 2 times a week times 8 weeks, 1 time a week times 1 week, and 2 PRN visits for wound complication. Review of the clinical record indicated the following: *8/4/25 SN visit, note was completed on 8/7/25. *8/18/25 SN visit, note was completed on 8/24/25. *8/22/25 SN visit, note was completed on 8/29/25. 5. Patient #17 was admitted to the agency in June 2025 with a diagnosis of cerebral infraction. Review of the Physician ordered Plan of Care for certification period 6/6/25 through 8/5/25 indicated the following: -SN visit 1 time a week times 6 weeks, and 2 visits PRN. -PT 1 time a week times 3 weeks, 1 every other week times 2 weeks, and 1 time a week times 3 weeks. -OT 1 time a week for 1 week. -Speech Therapy (ST) 1 time a week for 1 week, 1 every 2 weeks for 4 weeks, and 1 time a week for 3 weeks. Review of the clinical record indicated the following: *6/25/25 SN visit, note was completed on 6/30/25. *7/2/25 ST visit, note was completed on 7/7/25. *7/10/25 ST visit, note was completed on 7/14/25. During an interview on 9/10/25 at 2:45 P.M., the Executive Director said that visit notes should be completed by the clinician within 24 hours. Review of the agency policy entitled, Coordination of Care, From Admit Through Discharge, revised 9/1/24, indicated the following: *Completed visit notes will be submitted to the agency via synchronization within 24 hours of visit for point of care agencies. 1. Patient #2 was admitted to the agency in April 2025 with a diagnosis of age related osteoporosis with current pathological fracture. Review of the physician ordered Plan of Care for certification period 4/16/25 through 6/14/25 indicated the following: -Skilled Nurse (SN) visit once a week for 4 weeks. Review of a physician order, dated 5/15/25, indicated the following: -Occupational Therapist (OT) visit, effective 5/11/25, once weekly for 2 weeks, once every 2 weeks times 2. Review of the clinical record indicated the following: *5/2/25 SN visit, note was completed on 5/6/25. *5/19/25 OT visit, note was completed 5/21/25. 2. Patient #5 was admitted to the agency in May 2025 with a diagnosis of dementia. Review of the physician ordered Plan of Care for certification period 5/22/25 through 7/20/25 indicated the following: -SN visit once a week for 7 weeks, 2 as needed (PRN) for cardiac complications. -Physical Therapy (PT) visit, effective 5/25/25, once weekly for 6 weeks. -OT visit, effective 5/25/25, once weekly times 5 weeks, once every 2 weeks times 2. Review of the clinical record indicated the following: *5/29/25 SN visit, note was completed on 5/31/25, *6/13/25 SN visit, note was completed on 6/15/25. *7/3/25 SN visit, note was completed on 7/5/25. *5/28/25 PT visit, note was completed on 5/31/25. *6/16/25 PT visit, note was completed on 6/20/25. *6/24/25 PT visit, note was completed on 6/26/25. *6/11/25 OT visit, note was completed on 6/15/25. *6/16/25 OT visit, note was completed on 6/22/25. *6/23/25 OT visit, note was completed on 6/25/25. 3. Patient #6 was admitted to the agency in April 2025 with a diagnosis of Alzheimer’s Disease. Review of the physician ordered Plan of Care for certification period 811/25 through 10/9/25 indicated the following: -SN visit twice a week for 2 weeks, once a week for 6 weeks. -PT, effective 8/17/25, once a week for 6 weeks. -OT, effective 8/17/25, once a week for 8 weeks. Review of the clinical record indicated the following: *8/13/25 SN visit, note was completed on 8/15/25. *8/15/25 Licensed Practical Nurse (LPN) visit, note was completed on 8/18/25. *8/22/25 SN visit, note was completed on 8/25/25. *9/5/25 SN visit, note was completed on 9/8/25. *8/18/25 OT visit, note was completed on 8/21/25. *9/2/25 OT visit, note was completed on 9/7/25. During an interview on 9/10/25 at 3:50 P.M., the Patient Care Manager after reviewing the clinical records for Patients #2, #5 and #6, said the visit notes were late and not completed with the required timeframe.”

“Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure rehabilitative therapy services provided by a Physical Therapy Assistant were under the supervision of a Physical Therapist (PT). Findings include: Review of the agency policy titled Physical Therapy Assistant (PTA) Supervision, revised 8/1/25, indicated the following: *The PT provides supervision for every patient receiving care by the PTA to ensure that the patient is receiving satisfactory care. These visits are made according to specific state guidelines outlined below: *Massachusetts - Supervision requires presence of all parties at regularly scheduled supervision sessions and instructed according to the supervisee’s qualifications, position, level of preparation, depth of experience, and the environment within which the supervisee functions. Patient #11 was admitted to the agency in August 2025 and had a diagnosis of mild cognitive impairment. Review of the Physician ordered Plan of Care with benefit dates 8/1/25 through 9/29/25 indicated the following: -PT visit one time for one week (8/1/25 to 8/2/25) and twice a week for 3 weeks (8/3/25 to 8/23/25). -PT visit once a week for 5 weeks (starting 8/25/25). Review of the clinical record indicated the following visits were provided: -PT 8/1/25 -PTA 8/6/25, 8/8/25, 8/11/25, 8/14/25, 8/18/25, 8/21/25, 8/27/25 -PT 9/5/25 (supervisory functions not performed) -PTA 9/10/25 Further review of the clinical record failed to indicate PTA supervision occurred from 8/6/25 through 9/10/25 as required. During an interview on 9/10/25 at 4:25 P.M., the Director, after reviewing the clinical record for Patient #11, said PTA supervision did not occur as required.”