Blue Hills Therapeutics Inc.

“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 ensure Outcome and Assessment Information Set (OASIS) assessments were transmitted to Centers for Medicare and Medicaid Services (CMS) within 30 days of completing the assessment of the beneficiary, as required. Review of the agency’s Home Health Agency Error Summary Report dated January 1, 2024, through December 31, 2024, indicated that 367 of 598 OASIS Assessments processed were submitted more than 30 days after completion. During an interview on 2/25/25 at 10:00 A.M., the Administrator said that the data on the Error Summary Report was correct, and those 367 OASIS Assessments were submitted late. She said that she did not have access for IQIES/HARP right away last year when she took over as the Facility Administrator after the previous Administrator left.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on clinical record review, interview, and policy review, the agency failed to ensure that clinical notes were completed timely for 2 Patients (#3 and #4), out of a total sample of 7 patients. Findings include: Review of the Agency’s policy entitled, Documentation Policy, dated April 2013, indicated the following: *Purpose: To provide guidelines for the timely receipt of visit notes and Outcome and Assessment Information Set (OASIS) documentation. *All field staff will complete visit note documentation within 2 days (48 hours) of the visit. Visits must be signed by the clinician who completed the care within 48 hours of the date of the visit. 1. For Patient #3, the Agency failed to ensure that nursing staff signed and dated their visit notes within 48 hours of the visit. Patient #3 was admitted to the Agency in December 2024 with a diagnosis of Diabetes Mellites, requiring daily insulin injections. Review of the physician orders Home Health Certification Plan of Care (POC), dated 12/19/24 through 2/16/25, and 2/17/25 through 4/17/25, included the following orders: -Effective 12/19/24 - 1 skilled nurse (SN) visit 3 times a week for 1 week, then 7 times a week for 7 weeks. -Effective 2/17/25 - 1 SN visit 6 times a week for 1 week, then 7 times a week for 7 weeks. Review of the clinical record indicated the following: *SN visit made on 12/29/24, however it was not signed and dated until 1/6/25. *SN visit made on 1/3/25, however it was not signed and dated until 1/9/25. *SN visits made on 1/10/25, 1/11/25, 1/17/25, 1/19/25, 1/24/25, 1/26/25, however they were not signed and dated until 1/30/25. *SN visits made on 1/25/25, and 1/31/25, however they were not signed and dated until 2/3/25. *SN visits made on 2/7/25 and 2/8/25, however they were not signed and dated until 2/13/25. *SN visits made on 2/20/25 and 2/21/25, however they were never signed or dated. 2. For Patient #4, the Agency failed to ensure that nursing staff signed and dated their visit notes within 48 hours of the visit. Patient #4 was admitted to the Agency in August 2017 with a diagnosis of PTSD and Bipolar Disorder. Review of the physician orders Home Health Certification Plan of Care (POC), dated 12/30/24 through 2/28/25 included the following orders: -Effective 12/30/24 - 1 skilled nurse (SN) visit 4 times a week for 1 week, then 5 times a week for 8 weeks. Review of the clinical record indicated the following: *SN visit made on 1/3/25, however it was not signed and dated until 1/8/25. *SN visits made 1/10/25, 1/17/25, 1/24/25, however they were not signed and dated until 1/30/25. *SN visits made 1/23/25, and 1/30/25, however they were not signed and dated until 2/3/25. *SN visit was made on 2/7/25, however it was not signed and dated until 2/13/25. *SN visits made on 2/20/25, and 2/21/25, however they were never signed or dated. During an interview on 2/25/25 at 2:30 P.M., the Administrator said staff should sign and date their documentation with 48 hours of the visit.”