Good Samaritan Society - Home Care

“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 for 6 of 6(P18, P19, P20, P21, P22, P23) patients reviewed. Findings include: The Center of Medicare and Medicaid (CMS) Outcome and Assessment Information Set (OASIS) Error Detail Report dated 1/1/25 through 8/14/25, identified eleven patients whose OASIS assessment records were submitted more than 30 days after the assessment had been completed. P18’s plan of care (POC) identified a start of care date (SOC) of 2/3/25. P18’s start of care OASIS assessment with completion date 2/3/25, was submitted to CMS 3/7/25, 32 days after completion of the assessment. P19’s POC identified a SOC date of 12/8/24. P19’s recertification OASIS assessment with completion date 3/3/25, was submitted to CMS 4/10/25, 37 days after completion of the assessment. P20’s POC identified a SOC of 4/6/25. P20’s start of care OASIS assessment with completion date 4/6/25, was submitted to CMS 5/15/25, 39 days after completion of the assessment. P21’s POC identified a SOC of 1/26/25. P21’s start of care OASIS assessment with completion date 1/26/25, was submitted to CMS 5/23/25, over 80 days after completion of the assessment. P22’s POC identified a SOC of 3/5/24. P22’s discharge OASIS assessment with completion date 3/25/25, was submitted to CMS 5/31/25, 66 days after completion of the assessment. P23’s POC identified a SOC of 5/17/25. P23’s start of care OASIS assessment with completion date 5/27/25, was submitted to CMS 7/9/25, 38 days after completion of the assessment. During an interview on 8/20/25 at 2:53 p.m., Utilization review (UR) stated they were the staff members who submitted the OASIS to CMS. After the nursing staff completed all the needed information and it was reviewed, the submission would take place. UR reviewed P18 through P23’s OASIS submissions and confirmed they had been submitted after the 30 day limit and stated this happened, “for various reasons.” During an interview on 8/20/25 at 3:18 p.m., the administrator stated an expectation UR would review the OASIS information within 48 hours of completion, and if needed to nursing staff would respond to UR’s request for further information needed so the OASIS could be submitted to CMS in 30 days or less. Facility policy OASIS- Home Health. last reviewed 7/2025 indicated the OASIS data collection would be updated and submitted within 30 days of the completion of the OASIS completion. 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”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on interview and document review, the agency failed to provide 1 of 2 patients (P17) with information required related to other available home care providers, at the time of a agency-initiated discharge. Findings include: P17’s plan of care (POC) 5/1/25 to 6/29/25, identified a start of care (SOC) 5/1/25. Diagnoses included lymphedema, polyosteoarthritis, hypertension and anxiety disorder. Services included skilled nurse visits (SNV) one time per week for three weeks then two times every thirty days for various assessments and education. Physical therapy (PT) one time per week for four weeks to improve functional mobility and occupational therapy (OT) one time per week for two weeks for strengthening, home exercise program to improve use of upper extremities. P17’s OT visit note dated 6/10/25, identified an OT visit was made for a routine visit. Edema management and progression with POC was discussed with P17’s caregiver with education and training completed. Documentation included to anticipated discharge from OT soon due to P17’s noncompliance with treatment suggestions. P17’s OT visit note dated 6/18/25, identified an OT visit was made to discharge patient from the agency due to ongoing refusals and noncompliance with treatment recommendations. P17 signed a Notice of Medicare Non-Coverage (NOMNC), (a written notification to inform Medicare beneficiaries their covered services would be ending) for discharge from the agency effective 6/20/25. P17’s SNV note dated 6/20/25, identified a SNV was made to discharge P17 from the agency. The documentation did not identify if P17 had received information for other home care providers in her area that may provide home care services. P17’s medical record was reviewed and lacked documentation P17 had received information related to other available home care providers in her area at the time of the agency-initiated discharge from home care services. During interview on 8/20/25 at 3:00 p.m., the administrator stated P17 had been discharged from the agency due to noncompliance with treatment. The administrator stated she was the one who sent out information to patients after discharge, informing them of other agencies available in the area, however, was unable to find if she sent the form out to P17. P17 should have received the list of other agencies available but it had been missed. The agency’s Discharge and Transfer policy dated 7/30/24, identified discharge/transfer protocol would be adhered to according to state and federal regulations and the patient would be informed in a timely manner of the impending discharge, continuing care requirements and other available services if needed.”

“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 document review, the agency failed to ensure each patient had an initial assessment visit for resumption of care within 48 hours of the patient’s discharge from the hospital for 1 of 2 patients (P15) reviewed in the sample. Findings include: P15’s plan of care (POC) for certification period 5/11/25 to 7/9/25, identified start of care (SOC) was 3/12/25. Diagnoses included stage 4 pressure ulcer, heart and kidney disease, diabetes, hemiplegia and urinary retention. Services included skilled nurse visits (SNV) one time per week for nine weeks for wound care, assess/instruct regarding fall and safety precautions, cardiovascular status and complications, skin care, catheter care, and home exercise program. P15’s Hospital Care Management summary dated 5/15/25, identified P15 was hospitalized with planned discharge to home on 5/16/25. A referral and face to face attestation for home health care was completed. The referral identified P15 would require home health services for home infusion therapy for intravenous (IV) antibiotics, physical and occupational therapies for safety, assess equipment needs and fall prevention. The appointment urgency was to resume home care services within one to two days. The document identified the referral was faxed to the home care agency on 5/16/25. Review of P15’s clinical record identified P15 was discharged to home on 5/16.25, however, was not readmitted to home care services until 5/19/25. The clinical record failed to identify any reason why P15 had not been assessed within 48 hours of his return home from the hospital, and lacked evidence P15’s physician was notified of the delay in the resumption of care (ROC). When interviewed on 8/20/25 at 4:20 p.m., the administrator indicated hospital discharge orders to resume home care services were received on 5/16/25, however, she was unable to find a reason why P15 was not seen prior to 5/19/25. The administrator stated P15’s ROC was not completed in the required time frame of 48 hours, and it should have been done sooner. The administrator was unable to find a reason the ROC had not been completed more timely. The agency’s policy Admission Process dated 12/12/24, identified patients who were accepted for service should be admitted into the agency within 48 hours of referral unless otherwise specified by the provider.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, interview, and document review, the agency failed to ensure medications were reconciled and/or set up as ordered for 2 of 7 patients (P6, P8) whose medications were reviewed during home visits and record review. Findings include: P6 P6’s plan of care (POC) with a certification period of 8/2/25 to 9/30/25, identified a start of care (SOC) date of 8/2/25. Diagnoses included burst fracture first cervical vertebrae, hypertensive heart disease, systolic and diastolic heart failure (a serious condition that occurs when the left ventricle can’t pump blood efficiently), dysphagia (difficulty swallowing), emphysema (long-term lung condition that causes shortness of breath) and atrial fibrillation (an irregular heart rhythm). Services included skilled nurse visits (SNV) to evaluate and develop a plan of care, assess and evaluate co-morbid conditions, including hypertension, heart failure, emphysema and other conditions that present themselves during the care episode to identify changes and minimize complications and teaching medications. Occupational therapy (OT) to establish and upgrade a home exercise program and provide therapeutic exercises. Physical therapy (PT) for gait and balance, speech therapy for swallowing. P6’s Patient Instructions for discharge orders dated 7/31/25, identified numerous current outpatient medications ordered which included the following: -acetaminophen 500 milligrams (mg) take 2 tablets three times (TID) per day. -albuterol sulfate inhaler, inhale 2 puffs every hour as needed (PRN) for wheezing or shortness of breath. -calcium carbonate 500 mg 1 tablet every day. -diltiazem 30 mg take 1 tablet TID. -furosemide 20 mg take 1 tablet (20 mg) every morning and ½ tablet (10 mg) daily at noon. -ipratropium-albuterol nebulizer solution, inhale 3 millimeters (ml) every 6 hours PRN for wheezing. -polyethylene glycol 17 grams (gm) take 17 gm daily. However, P6’s POC dated 8/2/25, and P6’s Client Medication Report listed her current outpatient medications ordered which incorrectly listed P6 was to take furosemide 20mg 0.5 mg at noon for edema as well as omitted furosemide 20 mg every morning entirely. P6’s POC and Medication Report also failed to list the ordered albuterol inhaler and ipratropium-albuterol nebulizer solution which was ordered on her 7/31/25 discharge orders. During a home visit on 8/20/25 at 10:30 a.m., P6 stated she took her medications on her own. P6 brought out her medication bottles and cards to review. P6 stated she did not take acetaminophen on a scheduled basis and in fact rarely took the medication at all. P6 reported she used her PRN albuterol inhaler and ipratropium-albuterol nebulizer solution a few times daily. P6 stated she did not have or take calcium or polyethylene glycol and did not have the medications in her home. P6 stated she took diltiazem 30 mg one tablet every day and not three times per day as ordered and furosemide 20 mg one tablet every day however, did not take any additional furosemide including the 10 mg at noon as ordered. During interview on 8/20/25 at 11:30 a.m., registered nurse (RN)-A stated she had not reviewed P6’s medications during her visit the week prior. RN-A stated she needed to draw blood for labs, she was having difficulty with that and with the time constraints, she did not have the time to review medications during that visit. During review of P6’s medications during this week’s visit, her medication list was not accurate or up to date and it should have been. RN-A stated the usual procedure was to go through the discharge medication orders and compare with a patient’s medications in the home on admission. If discrepancies were noted or lack of prescriptions needed in the home, she would notify the primary physician and clarify the orders. RN-A stated the medication report would then be updated, which would generate a physician’s order to sign, and she would then assist the patient to obtain any missing prescriptions and educate on current medication regimen. RN-A did not feel a thorough medication reconciliation and review had been completed when P6 was admitted to the agency. The medication discrepancies should have been noted during subsequent SNV, as well and the medication report updated. P8 P8’s POC with a certification period of 7/23/25 to 9/20/25, identified a SOC date of 7/23/25. Diagnoses included hemiplegia following a cerebral infarction, stage 2 pressure ulcer of sacral region, hypertension, malignant neoplasm of the bladder and secondary neoplasm of bone, liver, and brain. Services included SNV to evaluate and develop a plan of care, assess and evaluate co-morbid conditions, including hypertension, pressure ulcer, aphasia, cancer, and other conditions that present themselves during the care episode to identify changes and minimize complications and teaching medications. OT to establish and upgrade a home exercise program and provide therapeutic exercises. Physical therapy (PT) to restore functional strength and range of motion, and speech therapy to establish a treatment plan for the improvement of a cognitive communications/swallow disorder. R8’s Discharge Summary dated 7/18/25, identified numerous current outpatient medications ordered which included the following: -enoxaparin (a blood thinner) inject 50 mg subcutaneously (SQ) every 12 hours. -Gabapentin (used to treat seizures or nerve pain) 100 mg TID. -methocarbamol 750 mg 1 tablet every four times per day PRN for muscle spasms. -Tagrisso (to treat lung cancer) 80 mg one tablet daily. -Tylenol 325 mg two tablets every four hours PRN. However, P8’s POC dated 7/23/25, and P8’s Client Medication Report listed his current outpatient medications ordered which listed enoxaparin, Gabapentin, methocarbamol and Tagrisso as dosages per instructions and did not identify the ordered dosages of the medications. Methocarbamol was incorrectly listed four times per day and not PRN as ordered, and Tylenol was incorrectly listed as four times per day and not PRN as ordered. During a home visit on 8/19/25 at 10:15 a.m., family member (FM)-A stated she set up and administered P8’s medications daily. FM-A brought out P8’s medication bottles and cards to review. FM-A stated P8 does not take methocarbamol anymore, and did not take Tylenol on a scheduled basis. FM-A reported P8’s medication dosages remained the same as ordered on discharge and did not change. P8 also took Imodium every three to four days and had been for a long time due to chronic bowel issues. During joint interview on 8/20/25 at 2:00 p.m., with the agency’s clinical manager (CM)-A and administrator, CM-A stated the admitting nurse was supposed to compare the patient’s discharge orders to the medications the patient had in their home as well as the patient’s verbal report of medications. The nurse was to notify the primary physician of any discrepancies noted, clarify the orders, write a verbal order and update the patient’s medication report. Both the administrator and CM-A stated the agency had just changed computer programs and staff were all learning the system and could have contributed to the inaccurate patient medication lists, as they may have not been inputted accurately due to the new system. The administrator stated it was the agency’s practice for the nurses to review medications at each visit and update medication lists when needed. The agency policy Medication Management dated 10/18/24, identified at a minimum, medications would be assessed and reviewed at the time of the initial assessment, following provider appointments, after a change in patient condition, at the time of recertification and discharge from agency, when there was a concern about the patient’s medications and with every comprehensive assessment. Staff were directed to list all medications a patient was taking including nonprescription medications and clarify all medications, including name, dose and frequency. If a patient identified a dose had been changed or a medication discontinued, staff were directed to call the provider to address the change. All medications orders must include name, dose, frequency and route.”

“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 initiate and provide services as ordered on admission for 1 of 7 patients (P6) whose orders were reviewed during home visits. In addition, the agency failed to ensure medications were administered only as ordered by the provider for 1 of 7 patients (P9) whose orders and medications were reviewed during home visits. P9 P9’s plan of care (POC) for certification period 8/16/25 to 10/14/25, indicated a start of care date of 6/17/25. The POC lacked a lidocaine patch listed on the section titled, “Medications.” P9’s POC for certification period 6/17/25 to 8/15/25, also lacked a lidocaine patch listed in the medications section. P9’s home health admission orders dated 6/13/25, indicated P9 had been on a 4% lidocaine patch while at the care center but was scratched through and discontinued at time of discharge from the care center and admission to home health agency. During an observation on 8/19/25 at 2:08 p.m., registered nurse (RN)-B spoke with P9 about trying Lidocaine patches and then proceeded to go into another room for privacy and assisted P9 to place the lidocaine patch P9’s body. During an interview on 8/20/25 at 9:04 a.m., RN-B stated she had assisted P9 to place the lidocaine patch. There were orders for the Lidocaine patch that were part of the admission orders when the home health agency started care. The lidocaine patch had been on the original medication profile and medication list. She was not sure why it was not on the most recent POC and medication profile. RN-B stated there was no current order for the lidocaine patch. During an interview on 8/20/25 at 2:18 p.m., the administrator reviewed P9’s POC’s and acknowledged there were no orders for lidocaine patches to be administered. The home health agency admission orders were also reviewed and acknowledged the orders for lidocaine patches at the care center had been scratched out. The administrator stated an expectation the nursing staff would get orders for new medications and update the profile before setting up or assisting in the administration of those medications. Agency policy Medication Administration, Home Health dated 4/8/25, indicated a provider order was necessary on the POC or interim order sheet for any medication administered by the agency staff. Findings include: P6 P6’s plan of care (POC) 8/2/25 to 9/30/25, identified a start of care (SOC) date 8/2/25. Diagnoses included fracture of the first cervical vertebra (located in the neck), chronic combined systolic and diastolic heart failure (serious condition when the heart is unable to pump blood effectively), emphysema (lung disease), atrial fibrillation (irregular heartbeat) and dysphagia (difficulty swallow). Services included on the agency’s POC included skilled nurse visits (SNV) one time per week for one week, two times per week for one week and one time per week for three weeks, physical therapy (PT) one time per week for one week, occupational therapy (OT) one time per week for seven weeks and home health aide (HHA) one time per week for four weeks. P6’s home care referral faxed to the agency on 7/31/25, identified a Face-to-Face Attestation encounter for home health care had been completed on 7/31/25. Primary services ordered for home care included skilled nurse visits, physical therapy, occupational therapy, home health aide and speech therapy. Review of P6’s clinical record identified P6 was discharged to home on 7/31/25 and admitted to home care services on 8/2/25. Services for skilled nurse, PT, OT and HHA had been initiated; however, speech therapy had not been initiated as ordered. The clinical record failed to identify any reason why P6 had not been assessed and evaluated by a speech therapist or if the speech therapist had been notified of the need for services on P6’s admission to home care services on 8/2/25. The clinical record also lacked evidence P6’s physician was notified of the delay in speech therapy services. During a home visit conducted on 8/20/25 at 11:00 a.m., P6 was observed sitting in a chair with a cervical brace around her neck. P6 stated she had swallowing issues and choked easily. P6 stated no one had offered her speech therapy services since she had returned home. P6 stated she thought it would be a good idea to have a speech evaluation completed though, as she did have swallowing issues. During interview on 8/20/25 at 11:30 a.m., registered nurse (RN)-A stated she reviewed P6’s chart and could not find speech therapy had been ordered. The speech referral should have been made on admission and scheduled within one to two weeks of admission, and it had not been done. RN-A would make a speech therapy referral for P6 now. During joint interview on 8/20/25, at 3:00 p.m. with clinical manager (CM)-B and the administrator, CM-B stated the referral to start speech therapy services for P6 must have been missed. CM-B felt it may have been missed due to the agency had just changed to a new computer system and the agency staff were just learning how to work in it. P6 should have received a speech therapy evaluation and CM-B put in an order that day for one to be completed. The agency’s policy Treatment and Therapy Management dated 1/2/25, identified all new or modified orders for treatment or therapy should be communicated within 24 hours.”