Divine Healthcare Network

“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 each completed Outcome and Assessment Information Set (OASIS) to CMS within 30 days of completing the assessment of the client. Findings include: The Home Health Agency (HHA) Error Summary Report dated 1/1/25-12/4/25, indicated there were 94/446 assessments (21.08%) processed with errors. The agency’s OASIS Error Detail Report dated 1/1/25-12/4/25, indicated -3330, Record Submitted Late: The submission date is more than 30 days after M0090. During interview on 12/4/25 at 10:30 a.m., registered nurse RN-A stated she and the director of nursing (DON) were responsible for submitting the clients’ OASIS reports every 60 days. She further stated the process for submitting an OASIS was to go through each client and collect information (perform an assessment) and then fill out the form. RN-A stated she knows the OASIS assessments were supposed to be done within the last 5 days of the recertification period and verified they have been late due to personal issues and it has been emotionally challenging. During interview on 12/4/25 at 10:40 a.m., the office manager (OM) stated she receives an error report once the OASIS assessments are submitted and gives it to RN-A or the DON so they are aware. A facility policy regarding client reassessment (undated), indicated the comprehensive assessment will be updated and revised as often as the client’s condition warrants due to major decline or improvement in health status. The assessment will include OASIS data collection for all Medicare and Medicaid skilled clients. Reassessments must be done at least: - every second calendar month beginning with start of care (within last 5 days of the episode, including day sixty). This will occur unless there is a client elected transfer, a significant change in condition or discharge and return to the same agency during the 60-day episode. -within 48 hours of client return home from hospital admission of more than 24 hours for any reason other than diagnostic testing. Assessment may be done based on physician ordered resumption date -within 48 hours of discharge or transfer, -significant change in condition or new diagnosis.”

“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 reschedule missed visits, notify the physician, or provide education or documentation of the potential clinical impact of missed treatments or services for 3 of 3 patients (P2, P3, P8). P2’s care plan for certification period 10/28/25-12/26/25, indicated diagnoses of Post Traumatic Stress Disorder (PTSD), schizotypal disorder, type 2 diabetes, and received skilled nursing visits daily. The nurse visits included insulin administration, monitoring blood sugar readings, set up oral medications, and monitor for signs and symptoms of hypo/hyperglycemia (low/high blood sugar). P2’s skilled nursing missed visit note dated 9/2025, indicated client out with family for the day. Client will be seen the following day as scheduled. It further indicated the physician had not been notified of the missed visit and lacked documentation the visit had been attempted to be rescheduled or the patient had been educated on the potential impact of missing the visit. P3’s care plan for certification period 10/4/25-12/2/25, indicated diagnoses of type 2 diabetes mellitus, hypertension, and received skilled nursing visits once a week. The nurse visits included setting up medications, assessing the patient’s ability to manage diabetic disease process, monitor for signs and symptoms of hypo/hyperglycemia (low/high blood sugar), and assessing for pain management and safety. P3’s skilled nursing missed visit note dated 9/9/25 indicated client phoned nurse yesterday and stated she had a clinic appointment today at the time of SNV. Client stated she will contact nurse to complete SNV later in the week. Will continue to monitor and follow up as needed. It further indicated the physician had not been notified of the missed visit and lacked information if the patient had been educated on the potential impact of missing the visit. P3’s skilled nursing missed visit note dated 11/25/25, indicated the nurse did not feel well. Client’s medications are set up times weeks for said missed visits and emergencies. Client is aware of emergency procedures and aware of office phone number if needed. Will continue to monitor and follow up as needed. It further indicated the physician had not been notified of the missed visit and lacked documentation the visit had been attempted to be rescheduled or the patient had been educated on the potential impact of missing the visit. P8’s care plan for certification period 10/28/25-12/26/25, indicated diagnoses of epilepsy, schizoaffective disorder, Colles’s fracture of radius, and pain in unspecified hip. P8 received skilled nursing visits once a week which included setting up medications, encouraging medication compliance, assessing for seizure activity, safety in the home, and pain management. P8’s skilled nursing missed visit note dated 11/25/25, indicated the nurse did not feel well. Client’s medications are set up times weeks for said missed visits and emergencies. Client is aware of emergency procedures and aware of office phone number if needed. Will continue to monitor and follow up as needed. It further indicated the physician had not been notified of the missed visit and lacked documentation the visit had been attempted to be rescheduled or the patient had been educated on the potential impact of missing the visit. During interview on 12/3/25 at 2:10 p.m., the office manager/scheduler indicated she was responsible for putting in the primary schedule for skilled nursing visits and then the nurses would adjust them as needed. If the client called and canceled the visit, then she would ask the client how they are going to get their medications and would notify the nurse. If the nurse canceled the visit, then she would call the client and ask if they wanted a replacement. The office manager further stated all cancelled visits were supposed to go through the office and should be documented in a communication note. They do not notify the physician if the missed visit is rescheduled within the same week but if the missed visit is not rescheduled within the same week, the physician should be notified. During interview on 12/2/25 at 3:00 p.m., licensed practical nurse (LPN)-A stated she does not notify the physician regarding missed visits unless it was going to be longer then 7 days before she would be able to see the client again and she does not educate the clients on the potential clinical impact of the missed visits. During interview on 12/4/25 at 10:30 a.m., registered nurse (RN)-A stated they encouraged the nurses to call the doctor if there was a missed visit and they are supposed to be doing so. RN-A further stated the director of nursing (DON) was available to replace a nurse if needed but there was not a process in place to automatically replace the nurse for a missed visit. RN-A verified there was no documentation that education had been provided to the client on the potential impact of missing visits. During interview on 12/5/25 at 11:30 a.m., registered nurse (RN)-A stated they should be notifying the physician regarding missed visits but was unaware they should be providing education on the potential impact of missing the visit. The agency policy regarding clinical documentation (undated) indicated services not provided as ordered, and the reason for the missed visits will be documented and reported to the physician.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on observation, interview, and document review the agency failed to ensure all patient care orders, were part of the plan of care for 2 of 2 patients (P3, P5) reviewed for medication administration. P3’s care plan for certification period 10/4/25-12/2/25, indicated diagnoses of type 2 diabetes mellitus, hypertension, and received skilled nursing visits once a week which included medication set up. During observation on 12/2/25 at 2:30 p.m., licensed practical nurse (LPN)-A set up the following medications: Carvedilol 12.5 milligrams (mg) twice a day, Losartan 25 mg once per day, Pantoprazole 40 mg once per day, and Senokot Stimulant Laxative one tab twice a day. P3’s medication profile for certification period 12/3/25-1/31/26, did not include physician’s orders for these medications. P5’s care plan for certification period 11/20/25-1/18/26, indicated diagnoses of osteoarthritis, vitamin deficiency, and received skilled nursing visits once a week which included medication set up. During observation on 12/3/25 at 10:15 a.m., LPN-A set up the following medications: Swanson triple magnesium complex 400 mg one tab daily, Vitamin D3 25 mcg (micrograms), one capsule every day, Swanson cinnamon 375 mg two capsules a day, and Apple Cider Vinegar one tablet three times a day. P5’s medication profile for certification period 11/20/25-1/18/26, did not include physician’s orders for these medications. During interview on 12/3/25 at 11:00 a.m., LPN-A stated the nurses were responsible for updating the patient’s medication profiles and verified P3 and P5’s medication profiles were not updated with the medications above. LPN-A further stated this was due to the fact that some medications (particularly supplements) were only available when the patient could afford them. Also, the patient may want to take the supplement one week and then want to stop taking them the next. LPN-A also verified all medications including supplements should be included on the medication profile. During interview on 12/4/25 at 10:30 a.m., registered nurse (RN)-A stated the nurse who worked with the client was responsible for updating the medication profile or they could call her, and she would update it. RN-A further indicated all medications (including supplements and over the counter) should be on the medication profile, stating if the nurse sets it up, it should be on the medication list. The agency’s policy regarding medication administration (undated), indicated agency staff will administer medications as ordered by the physician. If clients have medications in their home and are taking them. Agency staff will contact the physician to verify orders and document the order in the client record and on the medication profile.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and document review, the agency failed to ensure clinical notes were entered for 1 of 1 patient (P4) receiving skilled nursing services. P4’s care plan for certification period 11/21/25-1/19/26 indicated diagnoses of Schizophrenia, depression, and received one visit every two weeks in order to administer Risperdal IM (intramuscular injection used to treat Schizophrenia), order/deliver medications, and encourage medication compliance. P4’s skilled nursing visits for 11/5/25, 11/12/25, 11/19/25 were entered in her medical record but the progress notes lacked documentation of what services were provided during the visit. During interview on 12/4/25 at 10:30 a.m., registered nurse (RN)-A verified she had completed P4’s skilled nursing visits on 11/5/25, 11/12/25, 11/19/25 but had not documented what services were provided during the visit and she wasn’t sure why she hadn’t completed them. RN-A further verified the skilled nursing progress notes should have been entered in P4’s medical record. The agency’s policy regarding clinical documentation (undated), indicated all skilled services provided by nursing, therapy, or social services will be documented in the clinical record. A separate note shall be completed for each visit/shift and signed and dated by the appropriate professional.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on interview and document review, the facility failed to ensure every home health agency (HHA) skilled professional, contributed to all phases of the QAPI program. This had the potential to affect all 110 patients receiving services from the agency. During review of the agency’s Quality Assurance and Performance Improvement (QAPI) binder, the last QAPI meeting was on 7/26/18, and there were only 5 members present which didn’t include all of the clinical staff. During interview on 12/5/25 at 9:15 a.m., the education and outreach director stated they initiated a QAPI program but “haven’t really done anything with it, because 2024 has been a rough year since the owner passed away.” She further stated the office staff have had “very informal meetings” where they talk about QAPI but verified there was no documentation of meeting minutes, attendance sign in sheets, and that not all staff were present or included on the discussions. During interview on 12/5/25 at 9:40 a.m., the office manager stated they have had informal QAPI meetings (specifically discussions) but not all staff were a part of it because it’s too hard to coordinate everyone’s schedules. The agency’s QAPI Plan dated 2021, indicated all skilled professional staff, including direct employees and contractors must provide input into and participate in the implementation of the agency’s QAPI program and be able to demonstrate its operation to CMS.”