Homecall

“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 with Executive Director (ED), in a 12-month period the agency did not transmit seventy-four OASIS assessments to the CMS system within 30 days of completing initial assessments, as required by regulation 484.45(a). This failure to adhere to the required time frame for Oasis transmission has the potential to compromise the accuracy and timeliness of data reporting and impact compliance with federal regulations. On 6/25/2025 review of the agency’s Error Summary Report for the period of 6/23/2024 through 6/22/2025 noted error #3330 with seventy-four records being transmitted beyond the 30-day requirement time frame.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on review of patient records and interview with agency staff, the agency staff did not communicate delays in the start of care (SOC) for 3 out 16 patients reviewed. Placing the patients at risk for adverse or negative health care outcomes. Patient: #2, #6, and #12 Findings included: The home health agency furnishing services must maintain communication to ensure that their efforts are coordinated effectively and support the objectives outlined in the patients plan of care. 1. All clinical staff members have the responsibility to communicate or refer patient care related issues to other professional disciplines to ensure the provision of optimal health care services and to prevent adverse outcomes. This did not occur, as evidenced by the review of patient records 6/25/2025 through 6/27/2025. a) On 6/26/2025, during the review of patient #2 medical record, it is documented that on 2/12/2024 the agency received and accepted a referral to provide skilled nursing services for the patient. It was documented on 2/20/2024 that the patient’s physician was contacted and a SOC date of 2/21/2024 was requested. A client coordination note dated 2/20/2024 requesting a 2/21/2024 SOC was approved by the physician. No documentation communicating the reason for the eight-day delay in communicating with the patient or to the referring physician was in the record. During the interview, the agency ED stated that the agency was having staffing issues and was unable to provide the referred services at the time of the request. b) On 6/26/2025, during the review of patient #6 medical record, it is documented that on 3/18/2025 the agency received and accepted a referral to provide physical therapy services for the patient. The start of care date is documented as 3/26/2025. A client coordination note dated 3/24/2025 requesting a 3/26/2025 SOC was approved by the physician. There was no documentation explaining the delay in contacting the physician for approval to delay the SOC. During the interview, the agency staff did not provide any further information or documentation for the delay. c) On 6/27/2025, during the review of patient #9 medical record, it is documented that on 6/16/2025 the agency received and accepted a referral to provide skilled nursing, physical therapy and occupational therapy services for the patient. The start of care date is documented as 6/21/2025. A client coordination note dated 6/20/2025 requesting a new referral from the physician. There was no documentation explaining the reason for the request or the four-day delay of care. During the interview, the agency staff did not provide any further information or documentation for the delay in care.”

“Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This Element is not met as evidenced by: Based on the review of patient records and interview with agency staff, physician orders were not followed for 2 out of 16 patients reviewed. Failure to follow all treatment orders placed the patient at risk for inadequate health care. Patient: #4 and 9 1. The agency has an obligation to follow all physician orders. This did not occur, as evidenced by the record reviews for 2 out of 16 patients. A) Review on 6/26/2025 of Patient #4 medical record noted a physician order of home health aide services for activities of daily living due to patient having limited mobility and needing assistance. The order was dated 4/28/2025. There was no documentation on the services being started. The ED stated that the agency did not have any aides to provide the service. There was no documentation of notification to the physician of the agency not being able to provide aide services at the time of order. A second order was received on 5/22/2026requesting aides service to start the week of 5/28/2025. The first aide visit occurred on 6/13/2025. There was no documentation explaining the eleven-day gap. When asked the agency staff were unable to provide an explanation for the lack of documentation. B) Review on 6/27/2025 of Patient #9 medical record noted a physician order of Physical Therapy (PT) and Occupational Therapy (OT). The order was dated 1/21/2025. The patient was admitted to the agency on 1/23/2025 and discharged on 2/7/2025. There was no documentation of occupational services being started and no documentation of the ordering physician being notified of the service not being provided to the patient. When asked the ED and the branch Clinical Director had no explanation for the OT service not being provided to the patient.”

“Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient’s condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA’s policies and procedures. This Element is not met as evidenced by: Based on review of the agency’s patient care conference attendance sheets on 6/26/2025 for the previous seven weeks, the home health aides have not been participants of the interdisciplinary team meetings. Failure to comply with regulations places patients at risk for inadequate health care. Home health aides are members of the interdisciplinary team, must report changes in the patient’s condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA’s policies and procedures. During interdisciplinary team meetings, all HHA staff involved in the patient’s care must be present for, and, where appropriate, should contribute to, any discussion regarding the patient’s care. This did not occur. On 6/26/2025, when asked for the agency interdisciplinary team meeting documentation for the prior 60 days, the ED presented for review the attendance sheets for the Waldorf, Annapolis, Salisbury, and Easton offices. The patient care conferences were noted as taking place weekly at each branch. The attendance sheets received covered the period from 5/1/2025 through 6/26/2025 and notes the two home health aides had not attended any of the meetings for the entire period of 5/1/2025 and 6/26/2025.”