Critical Care Visiting Nurses

“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 Home Health Agency (HHA) failed to electronically transmit completed OASIS (Outcome and Assessment Information Set) assessments (a comprehensive patient assessment) to the Centers for Medicare and Medicaid Services (CMS) system within 30 days after completing the assessment. This failure had the potential to affect funding for the agency. Findings include: Review of the CMS OASIS assessment reference manual, effective 01/01/23 and located at https://www.cms.gov/files/document/oasis-e-guidance-manual51622.pdf, directed that the OASIS assessments be transmitted to CMS within 30 days of completion. Review of the Transmission Summary Report provided by the facility, revealed OASIS assessments were submitted to CMS greater than the 30 days after the completion of the assessment for 65 assessments submitted for 2023 Quarter (Q) 1, 57 assessments submitted for 2023 Q2, 32 assessments submitted for 2023 Q3, 39 assessments submitted for 2023 Q4, 35 assessments submitted for 2024 Q1, 36 assessments submitted for 2024 Q2, 31assessments submitted for 2024 Q3, 33 assessments submitted for Q4, and 37 assessments submitted for 2025 Q1. During an interview on 05/28/25 at 2:30 PM, the Director of Clinical Services (DCS) and Administrator stated the HHA used the CMS manual for the completion and transmission instructions for the completion and submission of the patients’ OASIS assessments. The DCS and Administrator confirmed the HHA had failed to submit OASIS assessments within 30 days of completion. The DCS and Administrator also stated that OASIS assessments were delayed in being submitted due to HHA’s process for completing the OASIS for transmission. The DCS and Administrator stated that the Registered Nurse or Physical Therapist performed the assessment, and it was available to the HHA’s office. The DCS and Administrator stated the assessment information was then sent to a third party affiliated with the software vendor for coding with the patient’s diagnoses. The DCS and Administrator stated after the third-party contactor completed the coding, the assessment was returned to the HHA for corrections, if needed and acknowledged OASIS assessments were submitted more than 30 days after the completion of the assessment.”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on document review, policy review, and interview, the Home Health Agency (HHA) failed to provide information on its discharge and transfer policies in advance of furnishing care for seven out of seven sampled patients (Patients (P) 1, P2, P3, P4, P5, P6, and P7). This had the potential to affect the patient’s knowledge of the agency’s discharge or transfer criteria before provision of care. Findings include: Review of the agency’s current undated admission packet provided by the agency revealed it did not include information on the agency discharge or transfer policies. A review of an agency’s policy titled, Patient Admission Criteria, dated February 2024, revealed it included a list of items provided to the patient at the initial visit. The list did not include information about the agency discharge or transfer policies. During an interview on 05/27/25 at 2:30 PM, the Administrator confirmed that information about the agency discharge and transfer policies was not included in the admission packet or provided to the patient prior to furnishing care.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on document review, interviews, and policy review, the Home Health Agency (HHA) failed to provide the name and contact information for the Administrator for two of two patients (Patient (P) 1 and P3) reviewed during home visit observations. This failure had the potential to deter the patient or caregiver from verbalizing a complaint or concern due to the lack of direct contact information. Findings include:that the name of the Administrator was not included in the information provided to the patient/caregiver. The documentation revealed to call the “Administrator” and provided the main phone number for the agency. During an interview on 05/27/25 at 12:50 PM, Family (F) 1 confirmed that there was no information provided that included the name of the Administrator. 2. Review of documentation included in the home health folder provided to P3 during a home visit observation on 05/28/25 at 1:15 PM, revealed the name of the Administrator was not included in the information provided to the patient/caregiver. The documentation revealed to call the Administrator and provided the main phone number for the agency. During an interview on 05/28/25 at 1:25 PM, P3 confirmed that there was no information received from the agency other than what was included in the admission packet. During an interview on 05/29/25 at 10:40 AM, the Administrator stated, “The staff are supposed to bring the agency brochure along with my business card attached to it.””

“OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This Element is not met as evidenced by: Based on document review and staff interview, the Home Health Agency (HHA) failed to provide the OASIS (Outcome and Assessment Information Set) notice of privacy to eight of eight sampled patients (Patient (P) 1, P2, P3, P4, P5, P6, P7, and P8) reviewed for admission to the HHA for care and services. The HHA’s failure to inform patient of their right regarding OASIS privacy may violate the patient’s right to information privacy. Findings include: Review of the HHA’s policy titled, OASIS Statement of Patient Privacy Rights, revised 03/19, documented “Prior to furnishing care during initial evaluation visit, each non-maternal patient over the age of 18 will be informed verbally and in writing of their rights concerning OASIS data collection.” During an interview on 05/28/25 at 1:45 PM, the Administrator confirmed the HHA was not providing services to patients under the age of 18 nor maternal health patients. The Administrator also confirmed the HHA failed to provide the OASIS “Statement of Patient Privacy Rights” as required.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review, interview, and policy review, the Home Health Agency (HHA) failed to complete the patient comprehensive admission assessment within five calendar days after the start of care for three of five patients (Patients (P) 1, P4, and P5) reviewed for the completion of records. The failure to complete the Comprehensive Assessment in a timely manner has the potential to delay implementation of an effective plan of care. Findings include: Review of the agency’s policy titled, Initial Assessment/Comprehensive Assessment, dated February 2024, revealed “Completion of the Comprehensive Assessment …The start of care date is the first visit where the Agency actually provides hands on, direct care services or treatment to the patient … Must be completed in a timely manner consistent with the patient’s needs, but no later than 30 calendar days after the start of care.” The policy failed to identify the Comprehensive Assessment must be completed in five calendar days. Review of P1’s Comprehensive Assessment revealed the Start of Care (SOC) date was 04/22/25 and the Comprehensive Assessment was completed on 05/01/25 which was 10 days after the SOC. Review of P4’s Comprehensive Assessment revealed the SOC date was 12/27/24 and the Comprehensive Assessment was completed on 01/06/25 which was 10 days after the SOC. Review of P5’s Comprehensive Assessment revealed the SOC date was 02/20/25 and the Comprehensive Assessment was completed on 03/06/25 which was 14 days after the SOC. During an interview on 05/27/29 at 2:30 PM, the Administrator stated, “We give them until Friday to complete documentation or the following Friday if the visit was on a Friday, but the nurses are late. We have done training and are working on it.””

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on document review, interviews, and policy review, the Home Health Agency (HHA) failed to provide the patient or caregiver with a written schedule of medications. for two of two patients (Patient (P) 1 and P3) reviewed during home visit observations. This failure had the potential to result in medication errors. Findings include: Review of the agency’s policy titled, Patient Admission Criteria, dated February 2024, revealed “Develop a written medication schedule/instruction including: medication name, dosage, route and frequency and which medications will be administered by the agency staff.” 1.Review of documentation included in the home health folder provided to P1 during a home visit observation on 05/27/25 at 12:30 PM, revealed the lack of a medication list including the name of the medication, dosage, and frequency. During an interview on 05/27/25 at 12:50 PM, Family (F) 1 confirmed the lack of a medication list provided by the agency. 2. Review of documentation included in the home health folder provided to P3 during a home visit observation on 05/28/25 at 1:15 PM, revealed the lack of a medication list including the name of the medication, dosage, and frequency. During an interview on 05/28/25 at 1:25 PM, P3 confirmed the lack of a medication list provided by the agency. During an interview on 05/29/25 at 10:40 AM, the Director of Clinical Services (DCS) stated, “The nurse is expected to print the medication list and bring it to the patient at the next visit.””

“If concern identified, direct observation CFR(s): 484.80(h)(1)(ii) The supervisory assessment must be completed onsite (that is, an in person visit), or on the rare occasion by using two-way audio-video telecommunications technology that allows for real-time interaction between the registered nurse (or other appropriate skilled professional) and the patient, not to exceed 1 virtual supervisory assessment per patient in a 60-day episode. This Element is not met as evidenced by: Based on record review, interview, and policy review, the Home Health Agency (HHA) failed to complete an in person on-site home health aide supervisory visit every 14 days for one of two patients (Patient (P) 1) reviewed for home health aide services. This failure had the potential to result in unidentified patient or caregiver concerns or care not being provided as written in the home health aide care plan. Findings include: Review of the agency’s policy titled, Home Health Aide Supervision, dated February 2024, revealed “The Agency will conduct the 14-day supervisory visit during and on-site, in person visit.” Review of P1’s nursing notes indicated the Director of Clinical Services (DCS) documented a home health aide supervisory visit on 05/06/25 and 05/20/25. During an interview on 05/27/25 at 4:00 PM, the DCS stated he/she has “not done in person supervisory visits for this patient” and that he/she called on the phone to inquire about the home health aide care being provided.”