Northeast Professional Registry of Nurses, Inc.

“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 record review and interview, it was determined that the facility failed to submit Outcome and Assessment Information Set (OASIS) assessments between 4/28/24 to 4/27/25 for 1365 out of 4857 records. Findings include: Review on 4/30/25 of the Center for Medicare and Medicaid Services (CMS) “HHA [Home Health Agency] Error Summary by Agency” report for 4/28/24 through 4/27/25 revealed the error “-3330 Records Submitted Late: The submission date is more than 30 days after M0090 (date the assessment was completed) on this new record” was noted for 1365 assessments of 4857 assessments. Interview on 5/1/25 at approximately 10:30 a.m. with Staff A (Executive Director of Quality) confirmed the above findings and revealed that the agency did not submit OASIS assessments from 1/6/25 through 4/21/25.”

“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 record review, it was determined that the agency failed to provide physician services ordered in the plan of care for 4 of 17 patients reviewed. (Patient identifiers are #2, #4, #5, and #10.) Findings include: Patient #2 Review on 5/1/25 of Patient #2’s plan of care for the certification period of 4/19/24 through 6/19/24 revealed a physician’s order for physical therapy evaluation on 4/26/24, then two times per week for 1 week, then 1 time per week for 3 weeks. Review on 5/1/25 of Patient #2’s medical record revealed that physical therapy completed an evaluation on 4/26/24. Further review of the medical record revealed that there was no physical therapy visits provided for the week of 4/28/24 through 5/4/24. There was no documentation the physician was notified of the missed visit. Patient #4 Review on 5/1/25 of Patient #4’s plan of care for the certification period of 9/20/24 through 11/18/24 revealed a physician’s order for skilled nursing 1 time per week for 6 weeks beginning on 9/20/24. Review on 5/1/25 of Patient #4’s medical record revealed that there was no nursing visit completed for the week of 9/29/24 through 10/5/24. There was no documentation the physician was notified of the missed visit. Patient #5 Review on 5/1/25 of Patient #5’s plan of care for the certification period of 11/10/24 through 1/8/25 revealed a physician’s order for skilled nursing 1 time per week for 9 weeks beginning on 11/14/24. Review on 5/1/25 of Patient #5’s medical record revealed that there was no nursing visit completed for the week of 11/25/24 through 12/1/24. There was no documentation the physician was notified of the missed visit. Patient #10 Review on 5/1/25 of Patient #10’s plan of care for the certification period of 4/2/25 through 5/31/25 revealed a physician’s order for skilled nursing 1 time per week for 9 weeks beginning 4/9/25. Review on 5/1/25 of Patient #10’s medical record revealed that there was no nursing visit completed for the week of 4/20/25 through 4/26/25 and the physician. There was no documentation the physician was notified of the missed visit. Interview on 5/1/25 at approximately 10:00 a.m. with Staff B (Registered Nurse) confirmed the above findings for Patient #2, Patient #4, Patient #5 and Patient #10. Review on 5/1/25 of the agency’s policy titled “Missed Visits” Policy No. 2-057.1 revealed...”Missed visits out of compliance with ordered frequency will be communicated to the clinical supervisor and the patient’s physician...A missed visit will be rescheduled the same week if possible...Missed visits will be documented in the clinical record.””

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on interview and record review, it was determined that the agency failed to complete a supervisory assessment of the home health aide no less frequently than every 14 days for 2 of 5 patients reviewed for supervisory visits. (Patient identifiers are #4 and #7.) Findings include: Patient #4 Review on 5/1/25 of Patient #4’s plan of care for certification period of 9/20/24 to 11/18/24 revealed a physician’s order for a Home Health Aide 1 time per week for 14 weeks. Review on 5/1/25 of Patient #4’s nursing notes revealed no supervisory visits were made during the certification period. Interview on 5/1/25 at approximately 9:15 a.m. with Staff B (Registered Nurse) confirmed the above findings. Patient #7 Review on 4/30/25 of Patient #7’s plan of care for certification period of 2/13/25 to 4/13/25 revealed a physician’s order for a Home Health Aide 2 times per week for 6 weeks. Review on 4/30/25 of Patient #7’s nursing notes revealed that there was no supervisory visit made between 2/26/25 and 3/17/25 (18 days). Interview on 4/30/25 at approximately 1:00 p.m. with Staff A (Executive Director of Quality) confirmed the above findings. Review on 5/1/25 of the agency’s policy titled “Responsibilities/Supervision of Clinical Services” Policy No. 4-008.1 Section 6...”The Executive Director/Program Director will ensure that the following supervision is maintained within the organization”...A. “Home Health Aides: 1. Home health aide supervisory visits will be conducted on-site at least every fourteen (14) days by appropriate skilled personnel...can be made in conjunction with the home health aide or in his/her absence.””