Care Plus Home Health Agency Inc.

“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 documentation and interview, the facility failed to report all OASIS data collected in accordance with federal regulations. Total number of records submitted beyond the 30 days was three hundred and sixty, which equaled 27.84% of the submissions submitted. Findings include: On the HHA Error Summary by Agency report period of 3/1/24 to 3/14/25, the agency had an error code of -3330: record submitted late. The description included the submission was more than 30 days after completion on the new record. During an interview on 4/22/25 at 1:00 p.m., the director of nursing (DON) stated the agency’s normal OASIS assessment process was to have the licensed nurse complete in the patient’s electronic medical record and then office staff would transmit. The DON confirmed the agency staff had problems completing and submitting OASIS assessments on time related to various reasons including patient visit scheduling issues due to refusals, hospitalizations or need of an interpreter. The agency policy Encoding and reporting OASIS Data dated 2/3/25, identified the facility will electronically report all OASIS data collected in accordance with federal regulations including encoding individual client assessment within thirty days of completing the assessment and transmitted within thirty days of the Oasis completion.”

“Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient’s equipment when assisting with self-administered tests. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to ensure their Clinical Laboratory Improvement Amendment Certificate (CLIA) was current. Findings include: During document review on 4/21/25 at 10:00 a.m, it was noted the agency CLIA waiver had expired on 3/2/25. During interview on 4/21/25 at 10:15 a.m., the administrator stated he had inadvertently missed renewing the agency CLIA waiver and then immediately initiated the renewal online.”

“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 observation, interview and document review, the agency failed to ensure a registered nurse (RN) conducted an initial assessment to determine the immediate care, and support needs forty-eight hours from the initial referral date for 2 of 7 (P1, P6) patients reviewed for appropriate and timely start of care. Findings include: P1’s electronic medical record (EMR) and plan of care (POC) with certification dates of 3/31/25 to 5/29/25 identified a referral date of 1/10/25 and an admit date of 1/30/25. P1’s EMR lacked documentation as to why the initial admit wasn’t completed within forty-eight hours of referral and with no notification to the provider. P6’s EMR and POC with certification dates of 1/8/25 to 3/8/25 identified a referral date of 9/4/24 and an admit date of 9/10/24. P6’s EMR lacked evidence of provider notification and documentation as to why the initial admit wasn’t completed within forty-eight hours of referral. When interviewed on 4/22/25 at 1:00 p.m., the director of nursing stated the agency process is to have a patient admitted and comprehensive assessment completed within forty-eight hours of referral to ensure client safety and care needs. The DON confirmed a patient’s provider should be notified if the agency was unable to admit and complete and complete an initial assessment within 48 hours. The DON stated this was difficult at times related to referrals with incomplete patient information coming from county agencies and not being able to schedule the initial assessment with the patient themselves. The agency policy Comprehensive Client Assessment dated 2/3/25, identified the initial assessment visit must be held either within 48 hours of referral or within forty-eight hours of the client’s return home, or on the physician ordered start of care date to determine the appropriate care, treatment and services to meet client initial needs and his/her changing needs.”

“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 medications were set up only as ordered by a physician or allowed practitioner for 1 of 2 patients (P4) observed during a skilled nursing home visit. Findings include: P4’s plan of care (POC) with a certification date of 3/2/25 to 4/30/25, with a start of care (SOC) date of 3/18/22, identified the diagnoses of chronic obstructive pulmonary disease (COPD), Sjogren syndrome (an immune system illness), depression and anxiety, received skilled licensed nurse visits one time per week for medication management and set up and had medication orders for methotrexate (a medication used for inflammation) 2.5 milligrams (mg) four tablets every Monday and methotrexate 2.5 mg four tablets every Wednesday. During observation on 4/21/25 at 12:45 p.m., licensed practical nurse (LPN)-A added four tablets of methotrexate 2.5 mg into P4’s Wednesday section of her pill box. LPA also added the over-the-counter supplement Magnesium 400 mg each day in the med box which was not listed on P4’s medication orders. After completion of the medication box set-up, LPN-A was asked why P4’s medication box was set-up without the second doses of her methotrexate order and the additional magnesium with no order and stated P4 had only been taking one dose of her methotrexate and the magnesium per her preference. LPN-A acknowledged the normal agency process when managing a patient’s medication was to check the orders with the medications and ensure they matched and if not, she would need to communicate with the patient’s provider to clarify. LPN-A confirmed P4 had been taking only one dose of methotrexate and magnesium “for a while” and she had not updated the provider. When interviewed on 4/21/25 at 1:00 p.m., P4 stated she had stopped taking her Monday dose of methotrexate about ‘three to four months ago” and recently bought the magnesium supplement to help with constipation and had asked LPN-A to fill her med box this way. P4 denied any ill effects from taking her medications this way but agreed her provider and med list should be updated. When interviewed on 4/21/25 at 2:17 p.m., the director of nursing (DON) confirmed standard agency practice was to check the patient medication orders with the patient’s home medications to ensure accuracy with each visit and if there was a discrepancy the patient’s provider should be updated immediately. The facility policy Medication Set Up dated 2/3/25, identified the patient plan of care is the nurse’s responsibility to ensure that it is accurate and without errors, the medications are reviewed at each visit to determine if there are new or changed orders including over the counter medications.”