Stanley Jones and Associates

“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 document review and interview, the agency failed to timely encode and submit Outcome and Assessment Information Set (OASIS) in accordance with Center for Medicare (CMS) requirement. On the HHA Error Summary by Agency report with run date 4/17/25, the agency had an error code 0f -3330: record submitted late. The description included the submission was more than 30 days after M0090 on the new record. The report included the number of assessments with this error code was 37, which equaled 10.54% of the submissions during the time frame. During interview on 4/22/25 at 2:31 p.m., the administrator explained the submission process, which included the clinician completing the OASIS assessment, the assessment being sent to a quality and coding company, the clinician making any revisions necessary and then the assessment being submitted. The administrator stated she has a spreadsheet to track each admission and where it is in the submission process. The administrator confirmed there had been a number of submissions that were filed after the allotted time period for a variety of reasons, including issues with the software, assessments not being transmitted during her vacation, and clinicians not completing and closing the assessment in a timely manner. The administrator stated she was aware of the issue and has been involved in addressing the issues. Agency policy on OASIS transmission dated 10/18/21, included the agency would electronically transmit completed OASIS data for each patient within 30 days of the date of assessment.”

“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 interview and document review, the agency failed to follow the plan of care (POC) for occupational therapy (OT) visits for 1 of 7 patients (P5) reviewed for visit frequency. P5’s POC for OT dated 3/6/25, included OT visit frequency of 2 times per week for 1 week, followed by 3 times a week for 5 weeks, followed by 1 time a week for 3 weeks. Visits would include training on activities of daily living (ADLs), safety training, functional transfer training, and lymphedema management. P5’s OT visit note dated 3/20/25, included a narrative that P5’s wrapping (for lymphedema) was below her knees upon arrival. Note reports client did not know what to do with the wraps due to them slipping down. P5’s medical record included physician notifications for missed visits for OT on 3/24/25, 3/26/25, 3/28/25, 3/31/25, 4/2/25, 4/4/25. All missed visit notifications included the comment, “Therapist unavailable for session, and no other therapist available to provide treatment.” During interview on 4/23/25 at 9:22 a.m., the administrator stated a visit would be rescheduled as soon as possible if it was missed due to staff availability. The administrator stated ideally it would be within the same week. The administrator confirmed there were missed visits for P5 due to staff availability due to a vacation. The administrator stated they do attempt to let patient’s know ahead of time about planned time off for staff so a plan can be made and education provided. During interview on 4/23/25 at 10:40 a.m., P5 confirmed there were some missed OT visits and they were told about it ahead of time. P5’s daughter was able to provide lymphedema wrapping during that time and was comfortable with completing the task. During interview on 4/23/25 at 12:20 p.m., OT confirmed there were missed visits for P5 while she was away on vacation. OT confirmed she made sure family would be able to provide care while she was away and who to contact at the agency if questions came up while she was away. Agency policy on missed visits requested and not provided.”

“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 record review, the agency failed to initiate start of care (SOC) within required 48-hour time frame for 1 of 7 patients (P4) reviewed for SOC timing. P4’s plan of care with certification period 4/7/25 - 6/5/25, included a SOC date of 4/7/25. P4’s diagnoses included osteoporosis, bilateral osteoarthrosis of both knees (arthritis in both knees), and history of falling. P4’s functional limitations included ambulation and endurance. External referral for physical therapy dated 4/1/25, included a routine referral for physical therapy for history of falling, vertebra compression fracture, pain in both knees and debility. Referral included an urgency as “normal” and a start date listed as 4/1/25. During interview on 4/23/25 at 11:58, administrator stated a SOC visit was typically completed within 48 hours of receiving the order, unless the provider requests a different date. The administrator stated the referral for P4 was originally faxed to the outpatient physical therapy department, and the agency did not receive the SOC order until 4/2/25. The administrator stated the SOC was not completed within 48 hours due to staff availability. The administrator confirmed a new order for SOC was not completed and the provider was not updated on the delay in SOC. The administrator stated it was important to complete SOC visits within the time frame to ensure a smooth and safe transition for the patients. Agency policy for admission assessments dated 4/16/25, included evaluation for admission would be completed within 48 hours of the referral or on the date ordered by the physician. A note would be made in the clinical record if the patient requested a different SOC date.”

“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 complete a transfer assessment for 1 of 1 patients (R1) reviewed for hospital transfers. R1’s plan of care (POC) dated 2/24/25-4/24/25, included R1’s prognosis was “fair” and had diagnoses of an open wound to right lower extremity (RLE), cellulitis, and chronic heart failure. R1 was scheduled to get skilled nurse visits four times a week for one week, followed by three visits a week for seven weeks for wound care and medication teaching. R1’s missed visit note dated 3/4/25, included the patient was hospitalized. The comments section included “client admitted to the hospital on 03/03/25 for concerns for RLE cellulitis (a bacterial infection of your skin and the tissue beneath your skin) by Community Paramedics” and “no transfer done, due to amount of time client will be hospitalized.” R1’s missed visit note dated 3/6/25, included R1 would discharge from the hospital with a scheduled visit on 3/7/25. R1’s hospital discharge summary dated 3/6/25, included R1 was admitted 3/3/25 and discharged 3/6/25 with a principal diagnosis of right leg cellulitis. R1’s Outcome and Assessment Information Set (OASIS) other follow up dated 3/7/25, included the reason for the assessment as “other follow-up.” Assessment narrative included R1 was hospitalized 3/3-3/6 due to worsening cellulitis. During interview on 4/23/25 at 9:16 a.m., administrator stated an OASIS transfer should be completed within 48 hours of the patient being transferred to the hospital or of the agency learning about the transfer to the hospital. The administrator stated an OASIS transfer would not be completed if a patient was at the hospital only under observation and not officially admitted. The administrator confirmed R1 was admitted and should have had an OASIS transfer completed and not the OASIS follow up that was completed. Facility policy for transfers dated October 2024, included a “transfer” would be completed if a patient was admitted to a hospital for more than 24 hours.”