Atrium Health at Home Charlotte

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on clinical record review, and staff interviews, the agency failed to ensure OASIS [Outcome and Assessment Information Set] accuracy related to N0415 [high risk medications for 4 of 17 records reviewed [ # 1, 15, 16 and 8]. The findings included: 4. Patient #8 had an admission date of 5/12/2025 with a diagnosis of Acute and chronic respiratory failure with hypoxia (long-term “chronic” severe impairment of the respiratory system causing low blood oxygen levels and a sudden “acute” worsening of symptoms including shortness of breath). The Plan of Care (POC) for 5/12/2025-7/10/2025 included orders for skilled nurse (SN) visits 2 times a week for 2 weeks, 1 time a week for 4 weeks and physical therapy (PT) 2 times a week for 1 week, 1 time a week for 3 weeks. Review of the clinical record revealed PT #4 completed the Start Of Care (SOC) OASIS (Outcome and Assessment Information Set-collection of data elements that home health agencies use to assess and report on patient quality) on 5/12/25. Review of the OASIS question NO415 [high risk medications] indicated the patient’s only high-risk medication was a hypoglycemic (used to reduce blood sugar level). Review of the POC revealed the patient was also using Morphine extended release (opioid) 30 mg 1 tablet every 12 hours and Morphine 15mg 1 tablet every 4 hours as needed for pain. NO415 did not capture the use of an opioid. During an interview with the agency director on 5/21/25 at approximately 2:00 pm, the director confirmed the OASIS information was not accurate. 1. Patient # 1 had a Start of Care [SOC] date of 2/11/24 with an admitting diagnosis of encounter for fitting and adjustment of urinary device. Review of the clinical record revealed RN # 10 completed the SOC OASIS [Outcome and Assessment Information Set-assessment tool used to collect data on patient’s demographics, clinical status, functional status and service needs] on 2/11/24. Review of OASIS question N0415 related to high-risk medications indicated the patient was receiving an antipsychotic [psychiatric medication] medication. Review of the Plan of Care for the certification period 2/11/24-4/10/24 revealed no antipsychotic medication was ordered for the patient. During an interview with RN # 9 on 5/21/25 at approximately 2 pm, RN # 9 confirmed the OASIS [N0415] was answered incorrectly. 2. Patient # 3 had a Start of Care date of 2/6/24 with an admitting diagnosis of age-related osteoporosis [condition related to aging where bone density and strength decline]. Review of the clinical record revealed RN # 2 completed the SOC OASIS [Outcome and Assessment Information Set-assessment tool used to collect data on patient’s demographics, clinical status, functional status and service needs] on 2/6/24. Review of OASIS question N0415 revealed RN # 2 indicated the patient was not taking any high risk medications. Review of the Plan of Care for the certification period 2/6/24-4/5/24 revealed the patient was ordered an antiplatelet [aspirin 81 mg two times per day]. During an interview with RN # 9 on 5/21/25 at approximately 2 pm, RN # 9 confirmed the OASIS [N0415] was answered incorrectly. 3. Patient # 15 had a Start of Care [SOC] date of 5/7/25 with an admitting diagnosis of infection/inflammation response due to internal fixator of right femur. Review of the clinical record revealed RN # 8 completed the SOC OASIS [Outcome and Assessment Information Set-assessment tool used to collect data on patient’s demographics, clinical status, and service needs] on 5/7/25. Review of OASIS question N0415 revealed RN # 8 indicated the patient was taking an antibiotic and hypoglycemic medication. The OASIS did not indicate the patient was ordered an opioid [pain medication] or antiplatelet medication [medication that reduces the blood’s ability to form platelets. Review of the Plan of Care for the certification period 5/7/25-7/5/25 indicated the patient was ordered children’s aspirin [antiplatelet] 81 mg two times a day and oxycodone [opioid] 5 mg every 6 hours. During an interview with RN # 9 on 5/21/25 at approximately 2 pm, RN # 9 confirmed the OASIS [N0415] was answered incorrectly. 4. Patient # 16 had a Start of Care [SOC] date of 4/23/25 with an admitting diagnosis of intrahepatic bile duct carcinoma [cancer]. Review of the clinical record revealed RN # 6 completed the SOC OASIS [Outcome and Assessment Information Set-assessment tool used to collect data on patient’s demographics, clinical status, functional status and service needs] on 4/23/25. Review of OASIS question N0415 related to high-risk medications indicated the patient was receiving an antipsychotic [psychiatric medication]. Review of the Plan of Care [POC] for the certification period 4/23/25-6/21/25 revealed no antipsychotic medications were ordered. Further review of the OASIS question N0415 revealed RN # 6 did not include the patient being ordered an opioid [pain medication]. Review of the POC revealed the patient was ordered Fentanyl 25 mcg/hr. transdermal patch. During an interview with RN # 9 on 5/21/25 at approximately 2 pm, RN # 9 confirmed the OASIS [N0415] was answered incorrectly.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on agency policy, observations, and staff interviews, the agency failed to perform proper hand hygiene for 1 of 7 home visits (#8); and failed to use a thermometer sheath for a thermometer used for other patients for 1 of 7 home visits (#8). Findings included: Patient #8 had an admission date of 5/12/2025 with a diagnosis of Acute and chronic respiratory failure with hypoxia (long-term “chronic” severe impairment of the respiratory system causing low blood oxygen levels and a sudden “acute” worsening of symptoms including shortness of breath). The plan of care for 5/12/2025 – 7/10/2025 included orders for skilled nurse (SN) visits 2 times a week for 2 weeks, 1 time a week for 4 weeks. During a joint visit on 5/19/2025 at approximately 2:30pm with RN #2 and the clinical team lead, RN #2 applied an excessive amount of hand sanitizer to her hands and then wiped the excess sanitizer off on her scrubs. RN #2 was observed using a thermometer without a sheath (clear, sanitary cover) while obtaining a temperature by mouth. During an interview conducted on 04/30/2025 at approximately 3:10 pm, the clinical team lead was asked what the expectations were in this situation. She acknowledged that based on agency policy, RN #14 should not have wiped her hands on her scrubs and should have used a protective sheath on the thermometer.”