Good Neighbor Hhc of Brainerd

“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 9 of 9 (P1, P2, P3, P4, P5, P6, P7, P8, P9) patients reviewed. The Center of Medicare and Medicaid (CMS) Outcome and Assessment Information Set (OASIS) Error Detail Report dated 1/1/24 through 12/12/24, identified eleven patients whose OASIS assessment records were submitted more than 30 days after the assessment had been completed. P1’s plan of care (POC) identified a start of care date (SOC) of 9/22/23. P1’s recertification OASIS assessment with completion date 5/15/24, was submitted to CMS 6/18/24, 34 days after completion of the assessment. P2’s POC identified a SOC date of 5/16/24. P2’s start of care OASIS assessment with completion date 5/16/24, was submitted to CMS 6/18/24, 33 days after completion of the assessment. P3’s POC identified a SOC of 5/25/23. P3’s recertification OASIS assessment with completion date 5/16/24, was submitted to CMS 6/18/24, 33 days after completion of the assessment. P4’s POC identified a SOC of 2/14/24. P4’s discharge OASIS assessment with completion date 5/22/24, was submitted to CMS 7/3/24, 42 days after completion of the assessment. P5’s POC identified a SOC of 7/31/24. P5’s discharge OASIS assessment with completion date 8/07/24, was submitted to CMS 9/11/24, 35 days after completion of the assessment. P6’s POC identified a SOC of 7/31/24. P6’s discharge OASIS assessment with completion date 8/07/24, was submitted to CMS 9/11/24, 35 days after completion of the assessment. P7’s POC identified a SOC of 3/09/23. P7’s discharge OASIS assessment with completion date 8/23/24, was submitted to CMS 9/25/24, 33 days after completion of the assessment. P8’s POC identified a SOC of 1/23/23. P8’s recertification OASIS assessment with completion date 9/13/24, was submitted to CMS 10/28/24, 45 days after completion of the assessment. P9’s POC identified a SOC date of 10/15/24. P9’s start of care OASIS assessment with completion date 10/15/24, was submitted to CMS 11/18/24, 34 days after completion of the assessment. During interview on 2/17/24 at 1:30 p.m. licensed practical nurse (LPN)-A stated she thought she needed to submit the agency completed OASIS assessments more than the two days monthly she currently had the task scheduled for. Holidays in the month interfered with submission dates and there were also times the agency nurses did not complete the assessment in a timely manner and that caused late submissions as well. During interview on 2/17/24, at 3:00 p.m. registered nurse (RN)-A stated LPN-A may need to change to submitting the OASIS assessments weekly to ensure they were submitted in the required time frame. 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).”

“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 observation, interview and document review, the facility failed to maintain a CLIA waiver and continued to engage 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. This affected 11 patients who received laboratory services. During an observation on 12/17/24 at 2:22 p.m., a Centers for Medicare and Medicaid Services (CMS) Clinical Laboratory Improvement Amendments (CLIA) Certificate of Waiver with an expiration date of 9/30/24 was mounted in a frame on a bookshelf in the conference room. An agency provided handwritten list undated, identified 11 patients received venipuncture (blood draw) and international normalized ratio (INR) (a standardized number that’s figured out in the lab and measure the time it takes for blood to clot) from the agency. During an interview on 12/17/24 at 2:30 p.m., the clinical manager (CM)-A stated the agency did collect patient blood draws and patient INR, however, brought the samples to the lab to be performed. Shirley and Sara stated they did not apply for a new CLIA waiver because they did not have a lab. Because of this, the agency did not believe they needed a CLIA waiver and did not re-apply. The agency policy Venipunctures undated, identified venipuncture was a technique in which a vein was punctured transcutaneously with a butterfly needle, a needle attached to a syringe or a vacutainer for the purpose of obtaining a blood specimen. The agency Preanalytic Policies and Procedures undated, identified it was the policy of the anticoagulation testing program to adhere to the following procedures, which govern all activities from the time tests were ordered through the time specimens were received and processed at the testing site. A policy and/or procedure regarding the application of a CLIA waiver was requested but not received.”