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 records reviewed from April 1, 2024, to March 26, 2025, the agency failed to ensure timely submission of OASIS assessments to the CMS system. The findings include: A review of the agency’s Error Report 3330 revealed that 42 OASIS assessments were submitted late, exceeding the 30-day submission requirement.”

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on medical record reviews, the agency’s staff failed to complete the patient’s visit frequencies as ordered in the plan of care (POC). The missed visits were undocumented, or the patient’s physician was not notified of the missed visit. This occurred for 6 out of 17 records reviewed. Missed visits and the lack of notification to the patient’s physician placed patients at risk for not meeting outcome goals and risk for delays in appropriate treatments and care. Patients: #1, #3, #4, #6, #7, #13 Findings include: 1. On 4/7/2025, review of patient #1medical record revealed on 3/15/2025 and 3/21/2025 the patient had missed visits for skilled nursing services. No documentary evidence shows the patient’s physician was notified of the missed visits. 2. On 4/7/2025, a review of patient #3 medical record revealed on the week of 3/16/2025 of patient’s care that no skilled nursing visit occurred to follow the 1w9w ordered visit frequency. Nor is there a missed note to indicate why the visit did not occur or that the patient’s physician was notified of the missed visit. 3. On 4/7/2025, a review of patient #4 medical record revealed a home health aide (HHA) visit frequency for 2wk4 effective 3/23/2025. There is no evidence to support any aide visits occurred, and no missed notes indicating why the visits did not happen. During an interview with the agency’s Executive Director, it was found the agency had no full-time equivalent (FTE) aide. The current HHA works prn (as-needed basis). 4. On 4/7/2025, a review of patient #6 medical record revealed that a skilled nurse (SN) missed visits on 8/8 & 8/9/2024 for caregiver/patient refused does not show that notification to the patient’s physician of the missed visits. 5. On 4/7/2025, a review of patient #7’s medical record revealed HHA services ordered for 2wk3 and 1wk3 effective 2/9/2025. No HHA visit occurred during the week of 2/9/2025, and there was no missed visit note to indicate why the visit did not happen. 6. On 4/7/2025, a review of patient #13 medical record revealed SN services ordered 2wk1, 1wk5, and 2 PRN. During week 1, only one SN visit occurred with no missed note indicating why the 2nd visit did not occur. To ensure the patient’s needs are still met, the physician should be notified of missed visits, and the agency should attempt to reschedule them.”

“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 a review of medical records, the agency’s administration failed to ensure that an assessment of the patient by nursing or rehabilitation therapy occurs within 48 hours of referral for 9 out of 17 patients. The agency not performing assessments timely placed the patients at risk for delays in care and adverse health care outcomes. Patients: #2, #5, #7, #8, #9, #10, #11, #12, #13 Findings include: 1. On 4/7/2025, a review of a patient #2 medical record revealed the referral date as 1/8/2025. The patient’s start of care (SOC) was 1/13/2025. There was no documentary evidence to support that the physician ordered the SOC. The 1/10/25 intake note indicates the physician is agreeable to 1/13/25 SOC. There is no way to recognize if the agency requested the SOC based on the agency’s availability; this should not occur. 2. On 4/7/2025, a review of a patient #13 medical record revealed the referral date as 10/8/2024. The patient’s SOC was 10/14/2024. There was no documentary evidence to support that the physician ordered this SOC. The 10/11/24 intake note indicates the physician is agreeable to the 10/14/24 SOC. There is no way to recognize if the agency requested the SOC based on the agency’s availability; this should not occur. 3. On 4/7/2025, a review of patient #12’s medical record revealed the referral date as 2/13/2025. The patient’s SOC was 2/19/2025. There was no documentary evidence to support that the physician ordered this SOC. The 2/18/2025 coordination note indicates the patient is agreeable to the 2/19/2025 SOC. There is no way to recognize if the agency requested the SOC based on the agency’s availability; this should not occur. 4. On 4/7/2025, a review of patient #11’s medical record revealed the referral date as 2/19/2025. The patient’s SOC was 2/26/2025. The 2/20/25 coordination note indicates a verbal order was received from the patient’s physician for a 2/21/25 SOC. 5. On 4/7/2025, a review of a patient #10 medical record revealed the referral date as 10/24/2024. The patient’s SOC was 10/28/2024. The 10/25/2025 intake note indicates that the physician is agreeable to 10/28/2024 to SOC. There is no way to recognize if the agency requested the SOC based on the agency’s availability; this should not occur. 6. On 4/7/2025, a review of a patient #9 medical record revealed the referral date as 10/30/2024. The patient’s SOC was 11/4/2024. The 11/1/2024 intake note indicates that the physician is agreeable to 11/4/2024 to SOC. There is no way to recognize if the agency requested the SOC based on the agency’s availability; this should not occur. 7. On 4/7/2025, a review of patient #8’s medical record revealed the referral date as 9/5/2024. The patient’s SOC was 9/9/2024. The 9/6/2024 intake note indicates that the physician is agreeable to 9/7/2024 but then agreeable to the 9/9/2024 SOC. There is no way to recognize if the agency requested the SOC based on the agency’s availability; this should not occur. 8. On 4/7/2025, a review of patient #7’s medical record revealed the referral date as 2/3/2025. The patient’s SOC was 2/8/2025. The 2/7/2025 intake note indicates that the physician is agreeable to the 2/8/2025 SOC. There is no way to recognize if the agency requested the SOC based on the agency’s availability; this should not occur. 9. On 4/7/2025, a review of a patient #5 medical record revealed the referral date as 3/10/2025. The patient’s start of care (SOC) was 3/20/2025. There was no documentary evidence to support that the physician ordered this SOC. The 3/19/25 intake note indicates the physician is agreeable to 3/20/25 SOC. There is no way to recognize if the agency requested the SOC based on the agency’s availability; this should not occur. Initial assessments must occur within 48 hours of referral, a patient’s return home, or the physician-ordered start of care date. An agency shall not request a change of the start of care to accommodate the agency’s convenience. Delays in care are a repeat deficient practice from the agency’s 2021 re-certification survey.”

“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: Home health aides are members of the interdisciplinary team. They must report changes in the patient’s condition to a registered nurse or other appropriate skilled professional and complete appropriate records required by the HHA. Failure to comply with regulations places patients at risk for inadequate health care. During interdisciplinary team meetings, all HHA staff involved in the patient’s care must be present and, where appropriate, should contribute to any discussion regarding the patient’s care. This did not occur. Findings include: 1. On 3/26/2025, a review of the agency’s interdisciplinary team meeting (case conference attendance records), records for the past 2 months included meetings on 2/5, 2/12, 2/19, 2/26, 3/5, 3/12, 3/19, 3/26/2025 revealed no HHA in attendance at the meetings. 2. The agency’s executive director confirmed during an interview that aides do not currently participate in the interdisciplinary team meeting.”