Caring Hands 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 (Outcome and Assessment Information Set) assessments to the Center of Medicare and Medicaid (CMS) system within 30 days of completing the assessment of the patient for 5 of 5 (P8, P9, P10, P11, P12) patients sampled from Oasis Error Detail Report. 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 180 patients 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 11/8/22. P8’s recertification OASIS assessment with completion date 10/28/24, was submitted to CMS 12/11/24, 44 days after completion of the assessment. P9’s POC identified a SOC date of 11/18/20. P9’s recertification OASIS assessment with completion date 10/29/24, was submitted to CMS 12/11/24, 43 days after completion of the assessment. P10’s POC identified a SOC of 3/14/23. P10’s recertification OASIS assessment with completion date 11/4/24, was submitted to CMS 12/11/24, 37 days after completion of the assessment. P11’s POC identified a SOC of 10/24/24. P11’s start of care OASIS assessment with completion date 10/29/24, was submitted to CMS 12/11/24, 43 days after completion of the assessment. P12’s POC identified a SOC of 10/31/24. P12’s start of care OASIS assessment with completion date 11/08/24, was submitted to CMS 12/11/24, 33 days after completion of the assessment. During interview on 4/21/24, at 2:00 p.m. owner/clinical manager (CM)-A stated she was responsible for submitting completed OASIS to CMS. CM-A had missed submitting some of the oasis. She had it on her agenda to do and then would get busy with other tasks and forget to get the OASIS submitted. CM-A thought she would need to just set one day a week adn submit any OASIS that were competed and she had not done that and so they were submitted late. CM-A thought when she on-boarded the new nurse she just hired, she may delegate the task of OASIS submissions to the new nurse, as she had a lot of experience with home care. Everything had gone hay wire the previous fall and CM-A just did not get the OASIS data submitted timely. 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).”

“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 agency failed to ensure each patient had an initial assessment visit within 48 hours of the referral date for 1 of 7 patients (P1) reviewed, in the sample. P1’s plan of care (POC) 12/20/24 to 2/17/25, identified a start of care (SOC) date 12/20/24. Diagnoses included anxiety, post-traumatic stress disorder, attention deficit hyperactivity disorder, bipolar disorder and migraine. P1’s clinical record identified a face-to-face physician visit was completed on 12/11/24, identifying P1 was in need of nursing home health services for difficulty with self-care and need for medication setup, however, P1 was not admitted to home care services until 12/20/24. The clinical record failed to identify a reason why P1 had not been assessed within 48 hours of the referral date of 12/11/24, and lacked evidence P1’s physician was notified of the delay in the SOC date. When interviewed on 4/23/25, at 9:17 a.m. the owner/clinical manager (CM)-A indicated orders for home care services were received on 12/11/24, however, the agency did not have staff available to admit that week. CM-A was sure she had notified P1’s social worker as well as his physician of the delay in SOC but had failed to document the telephone calls. The agency’s practice was to contact the primary physician and get a verbal order for the delay in the SOC date, but CM-A was unable to find such an order for P1. The agency’s undated policy, Admission of the Client to Home Care identified all persons referred would be considered for admission. Prospective client information would be received by the agency and reviewed by a registered nurse. Once the client was accepted, an RN would be assigned to complete the initial admission assessment and obtain initial signatures authorized care services, as well as establishing a service plan of care with the client. The policy lacked time frames for the initial assessment visit following receipt of a home care referral.”