Avera @ Home Pipestone

“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 interview and document review the agency failed to encode and electronically transmit completed Outcome and Assessment Information Set (OASIS) assessments to the Center of Medicare and Medicaid (CMS) system within 30 days of completing the assessment for 1 of 3 (P6) patients observed during home care visits. Findings include: P6’s plan of care (POC) identified a start of care date (SOC) 11/12/26. P6’s admission OASIS assessment with completion date, was submitted to CMS on 1/12/26, 60 days after completion of the assessment. During interview on 7/29/29 at 9:00 a.m., care manager (CM)-A and nurse manager (NM)-A verified the late OASIS submissions. At this time, there had been a transition with staff and a new person who was responsible for submissions. There was a batch of OASIS assessments that were missed during this time. The Center for Medicare and Medicaid Services OASIS E Manual, updated 1/1/24, identified OASIS data was collected as part of the comprehensive assessment required by the Medicare Conditions of Participation. The CMS Home Health Conditions of Participation required a home health agency to electronically transmit accurate, completed, and encoded OASIS data to a centralized data submission system within 30 days of the completion of the assessment (M0090 Date Assessment Completed).”

“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 interview and document review the facility failed to admit a patient within 48 hours of received referral or obtain a provider order to delay start of care (SOC) for 2 of 7 (P4, P5) patients reviewed for admissions. Findings include: A review of P4’s medical record on 7/29/26, indicated P4 had a referral date of 1/14/22. P4’s Plan of Care (POC) for certification period 1/17/22- 3/17/22, indicated P4’s SOC date was 1/17/22. P6 had diagnoses heart failure and lung disease and required a skilled nurse visit every other week. P4’s medical record lacked indication of a rationale for delayed SOC, or an alternate order had been obtained for P4’s SOC to be 6/17/26. A review of P5’s medical record on 7/29/26, indicated P5 had a referral date of 1/23/26. P5’s POC for certification period 1/28/26-3/28/26, indicated P5’s SOC was 1/28/26. P5 had diagnoses of Parkinson’s disease and heart disease and required skilled nursing visits weekly. P5’s medical record lacked indication of a rationale for delayed SOC, or an alternate order had been obtained for P4’s SOC to be 1/28/26. When interviewed on 7/26/29 at 1:21 p.m., clinical manager (CM)-A verified P4 and P5’s SOC occurred more than 48 hours after their referrals were received. Furthermore, CM-A stated there was no rational or new order obtained from the provider for the delayed SOC. An agency policy titled Initial and On-going Nursing Assessments of Clients revised 1/12/26, directed staff to complete a nursing assessment within 5 days of initiation of home care services. However the policy did not address the time frame required from referral date to the initial start of care.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observation, interview and document review, the agency failed to ensure medication reconciliation during medication set up was completed by provider orders and without errors for 1 of 1 patients (P1) observed during medication set up. Findings include: P1’s plan of care (POC) for certification period 7/9/26-9/6/26, indicated P1 had diagnoses of surgical aftercare following skin surgery, diabetes, and lung disease. P1 required skilled nursing services weekly for medication set up and assessments related to post surgical care and medical diagnoses. Furthermore, P1’s POC indicated P1 required the following medications: -Cranberry capsule 500 milligrams (mg) take 1,000mg by mouth morning and evening for supplement. -Methenamine mandelate 1 gram (gm) tablet twice daily for urinary tract infection prevention. -Metoprolol tartrate 25mg twice daily for high blood pressure. An observation and interview on 7/27/26 at 1:45 p.m., licensed practical nurse (LPN)-A was completing medication set up during a home visit for P1. LPN-A had a handwritten paper medication list that was used for reconciling P1’s medications and used for medication set up. As LPN-A went through P1’s medications, the following medications were included in the set up: -Cranberry capsule 4200mg daily, which was different from the orders on P1’s POC. -Methenamine Hippurate 1gm twice daily, which was different from the orders on P1’s POC. -Metoprolol tartrate 50 mg twice daily, which was different from the orders on P1’s POC. When the differences were pointed out, LPN-A verified the orders and bottles did not match up for the cranberry capsule, methenamine mandelate, and the metoprolol. LPN-A further stated when orders were changed, the handwritten medication sheet and the POC in the medical record both needed to be updated. LPN-A removed the medication, and stated follow-up would be needed with P1’s provider. A follow up interview on 7/27/26 at 4:04 p.m., LPN-A stated a new script was sent to pharmacy for the cranberry capsule. P1’s metoprolol was increased on 3/11/26, and the new dose was increased on the written paper medication record but had not been updated in the electronic medical record, which should have been done. P1’s Methenamine should be the Hippurate dosing instead of the mandelate and that medication was also sent to pharmacy. When interviewed on 7/27/29 at 4:15 p.m., clinical manager (CM)-A expected the POC in the electronic medical record to be updated when there were medication changes. Furthermore, nursing were expected to review the bottles to the medication order to ensure accuracy of medication set up and prevent errors. An agency policy titled Medication Management Services revised 1/12/26, directed staff to acquire a prescription for all medications managed for clients, including over the counter. The agency will develop and update the client’s medication records and medication management plan when necessary. Furthermore, during medication set up, the nurse will verify the dose of medication consistent with the prescription and review the client’s medication record when setting up medications.”