Pennington & Red Lake County Public Health & Home Care

“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 OASIS assessments to the Center of Medicare and Medicaid (CMS) system within 30 days of completing the assessment of the patient for 1 of 1 (P8) patient reviewed. The Center of Medicare and Medicaid (CMS) Outcome and Assessment Information Set (OASIS) Error Detail Report dated 1/1/24 through 12/31/24, identified one patient (P8) whose OASIS assessment records were submitted more than 30 days after the assessment had been completed. P8’s plan of care (POC) identified a start of care date (SOC) of 3/31/17. P8’s recertification OASIS assessment with completion date 10/16/24, was submitted to CMS 12/6/24, 51 days after completion of the assessment. During interview on 6/11/25, at 10:30 a.m. the director of nursing (DON) stated she was unable to find out the reason P8’s oasis had been submitted so late. She felt it must have been missed on the list for submission that week. 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 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). The agency’s undated policy Oasis Implementation and Transmission Policy, identified the agency would electronically transmit accurate, completed, encoded and locked OASIS data for each patient to the state agency no later than 30 days from the date assessment was completed. Rejected data would be corrected and re-transmitted to the state within the 30-day time frame.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and document review the agency failed to send a completed transfer summary to the receiving health care facility within two business days of becoming aware of the unplanned transfer to 1 of 2 patients (P7) reviewed for discharge. P7’s plan of care (POC) 4/3/25 to 6/1/25, identified a start of care (SOC) date 2/8/24. Services included skilled nurse visits (SNV) one time per week for nine weeks, plus one time per week as needed for medication changes. SNV to assess blood pressure, lung sounds, edema, skin, mobility, risk for falls and setup medications as ordered. A home health aide was ordered two times per week to assist with personal care such as bathing and skin care. Diagnoses included Parkinson’s. weakness and gait abnormality. A skilled nurse visit note dated 5/20/25, identified nurse manager (NM)-A had received a telephone call from P7’s son to notify her P7 had been seen by his primary provider that day and would be moving into the local nursing home that afternoon. NM-A documented P7 would be discharged from the agency. A discharge summary had been completed and sent to P7’s primary provider, however, P7’s medical record lacked evidence a transfer form had been completed and sent to the receiving facility as required. During interview on 6/11/25, at 10:30 a.m. the director of nursing (DON) stated the nurse manager had been notified by phone from P7’s son that P7 would be going to the nursing home that day. It was not a planned transfer. NM-A should have still sent a transfer form with a current medication list to the facility but had not done so. The agency needed to do better with some kind of communication with patient transfers. The agency undated policy Termination of a Client’s Home Care Services identified if a patient transferred to another health care provider or inpatient facility, the registered nurse would send a copy or summary of the patient’s record to the new provider or facility. The agency would participate in a coordinated transfer to a new provider.”