Mary T Home Health

“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 period of 12/18/2023 - 12/18/2024, 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 189, which equaled 16.41% of the submissions submitted. During an interview on 1/30/25 at 10:53 a.m., clinical manager (CM)-A confirmed the agency has had problems completing and submitting the assessments on time. CM-A stated the clinicians completing the assessment do not always complete them in a timely manner. After the assessment was closed by the clinician, it gets sent through a quality assurance process. The assessment was then submitted after the quality assurance process was completed. CM-A stated this process sometimes exceeds the required timeframe. Agency policy on OASIS submission data requested and not provided.”

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on interview and document review, the agency failed to ensure 1 of 5 non-licensed staff completed required annual training. Agency provided document titled Associate List dated 1/28/25, included home health aide (HHA)-B had a start date of 4/4/22. Agency provided undated document titled Home Care Annual EduCare (an online healthcare education and training platform) Plan included the monthly assigned courses with continuing education hours. Total number of hours assigned was 12 hours per year. Agency document titled My Transcript with HHA-B’s name, undated, included transcript of EduCare courses completed. Courses completed for last 12 months included: HIPPA completed 3/7/24 worth 1 credit Home Care Bill of Rights completed 4/4/24 worth 0.75 credits Infection Control Techniques completed 2/7/24 worth 1 credit Waste-Wise Recycling Program Training completed 1/17/25 worth 1 credit Total of 3.75 credits (hours) During interview on 1/30/25 at 10:34 a.m., clinical manager (CM)-A confirmed HHA-B had not completed the required number of hours of annual training. CM-A stated the agency assigns a course each month to allow staff time to complete the required education. CM-A stated the agency regularly runs a report to monitor for incomplete education. She was aware HHA-B was behind on her education and believed it was discussed at her yearly review November 2024. Facility policy for annual training requested and not provided.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on observation, interview, and document review the agency failed to identify, assess and educate 1 of 1 patients (P4) on use of a bedrail which was attached to his hospital bed. P4’s Home Health Certification and Plan of Care identified diagnoses of cerebral infarction (stroke), and low back pain with a care goal of improved bed mobility with intervention of physical therapy to instruct patient/caregiver on techniques to improve bed mobility and safety. P4’s durable medical equipment (DME) and supplies list included a hospital bed, shower chair, walker, wheelchair, elevated toilet seat and ramp. During observation and interview on 1/29/25 at 8:30 a.m., home health aide (HHA)-A was assisting P4 with a bed bath. P4 was noted to have a half rail on his hospital bed in the lowered position. When HHA-A was asked how P4 utilized the half rail she stated he sometimes would grab onto it in the lowered position to assist with sitting up or positioning in bed and had not seen it used in the raised position. When asked if any instruction or education had been provider to herself or P4 on appropriate and safe use of the half rail HHA-A stated not that she could remember. During interview on 1-30-25 at 9:50 a.m., clinical manager (CM)-A stated P4’s half bed rail had not been assessed for appropriate and secure placement and should have been included in P4’s DME list. CM-A confirmed P4 had not been educated on risks or safe use of the half rail. CM-A confirmed best practice would be to assess any bed rail for proper installation and safe use. CMA-A stated the agency had no policy or procedure regarding use of bed rails.”