Omnia Home Care LLC

“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, document review, policy review, and the Centers for Medicare and Medicaid Services (CMS) guidelines, the Home Health Agency (HHA) failed to maintain a system to ensure the transmission of Outcome and Assessment Instrument Sets (OASIS) to the internet Quality Improvement Evaluation System (iQIES) was accomplished within 30 days of completion. This deficient practice had the potential to impact the comprehensive assessment information incorporated into the affected patients’ plan of care. Findings include: Review of the agency’s Untimely OASIS Submission Report, prepared by the state OASIS Education Coordinator using data from the iQIES on 03/03/2026, indicated the agency had been non-compliant with the CMS guidelines requirements as evidenced by the late transmission of OASIS data.” Review of the OASIS Agency Final Validation report located in the agency’s iQIES reports, dated 10/01/2024 – 12/31/2025, confirmed OASIS data was transmitted late (more than 30 days after the completion date) as follows: During the third quarter of 2023, 12.5% (53 of 416) of OASIS data was transmitted late. During the third quarter of 2024, 10.5% (60 of 570) of OASIS data was transmitted late. During the fourth quarter of 2024, 11.2% (74 of 659) of OASIS data was transmitted late. The agency’s November 2020 policy, titled “OASIS Data Transmission” revealed, the organization would encode and transmit completed OASIS data for each applicable patient within thirty (30) days of the M0090 date [assessment date], date assessment completed. The organization would conduct clinical and data entry audits to verify collected OASIS data was consistent with reported OASIS data. On 03/10/2026 at 11:45 AM, the Administrator confirmed the late transmission of OASIS data and revealed the reason was due to a change in leadership, and there was fluctuation in management. Review of the CMS Home Health (HH) Quality Reporting Program (QRP) Quick Reference Guide dated 04/25/2024, located at https://www.cms.gov/files/document/pac-hh-quickreferenceguide-20240425.pdf indicated, “OASIS data must be transmitted [to CMS] within 30 days of the assessment date.””

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview, record review, and policy review, the Home Health Agency (HHA) failed to ensure a system was in place for authentication of physician orders via signature for 3 of 17 patients (Patient (P) 7, P12, and P15) records reviewed. This failed practice had the potential to place patients at risk for negative outcomes. Findings include: P7’s physician orders dated 03/03/2026 indicated for Occupational Therapy (OT) to evaluate and treat for safety in the home and assistance with Activities of Daily Living (ADLs). The visit frequency for OT/Certified Occupational Therapy Assistant (COTA) was one visit per week for one week, starting 03/03/2026. P12’s physician orders dated 02/13/2026 indicated effective 02/15/2026, the patient was to delay initiation of cardiac therapy until the week of 02/23/2026. The orders further indicated the patient continued to require assistance for bathing, showering, and other self‑care ADLs due to shortness of breath and generalized weakness. The patient would benefit from an extension of Home Health Aide (HHA)/Certified Nursing Assistant (CNA) services to ensure ADL safety. HHA services were ordered at one visit per week for two weeks beginning 02/15/2026. P15’s physician orders dated 02/23/2026 indicated, skilled nurse two times a week for two weeks for wound care. Visit frequency for a registered nurse/licensed practical nurse (RN/LPN) 2 x week for 2 weeks starting 02/22/2026. The agency’s policy titled, “Verification of Physician Orders” dated 11/2020 indicated, orders would be obtained from a licensed physician (or other authorized licensed independent practitioner) for care and services provided to home health patients. The original of the order would be attached to the next ‘Plan of Care’ to be delivered to the physician (or another authorized licensed independent practitioner) for signature. When the signed order form returned to the agency the copy would be removed from the clinical record and destroyed, and the original will be retained in the clinical record.” On 03/10/26 at 4:25 PM, the Administrator confirmed the patients’ physician orders were not signed by a physician and the physician orders went on the next plan of care or would go into the next recertification or discharge assessment.”

“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 record review, interview, and policy review, the Home Health agency failed to ensure the medication review included documentation of adverse reactions, side effects, duplicate drug therapy, or drug interactions identified during assessment and to document physician/practitioner notification of concerns identified for 10 of 17 patients (Patient (P)3, P4, P5, P6, P7, P8, P10, P11, P12, and P13). This failure had the potential to affect the health and well-being of all patients receiving services from the agency. Findings include: P3’s medication profile dated 12/18/2025 revealed the patient was taking celecoxib 200 milligrams (mg) twice daily, cefuroxime axetil 500 mg twice daily, aspirin 81 mg twice daily, rifaximin 550 mg twice daily, spironolactone 50 mg daily, potassium chloride 20 milliequivalents (mEq) daily, furosemide 40 mg daily, Omeprazole 40 mg every morning, vitamin D3 50 micrograms (mcg) twice daily, calcium citrate once daily, magnesium oxide 240 mg daily, biotin 5000 mcg daily, vitamin C 500 mg daily, lysine 500 mg daily, folic acid 800 mcg daily, vitamin E 180 mg daily, B complex daily, selenium 200 mcg daily, and oxycodone five (5) mg every eight hours as needed. The Drug Regimen Review section dated 12/18/2025 revealed the following: a. “Potential drug reactions or adverse effects” was marked “Y” (yes). b. “Potential or actual ineffective drug therapy” was marked “Y”. c. “Significant side effects” was marked “Y”. d. “Significant drug interactions” was marked “Y”. e. “Duplicate drug therapy” was marked “Y”. The comment section included instructions to document and describe any “Y” answers. The comment section documented “Verbalized understanding.” There was no description of the potential drug reactions or adverse effects, ineffective drug therapy, side effects, drug interactions, or duplicate drug therapy and no indication the physician was notified. P4’s medication profile dated 10/16/2025 revealed the patient was taking tolterodine tartrate 40 mg daily, calcium carbonate-cholecalciferol 600 mg/20 mcg daily, bupropion 75 mg daily, atorvastatin 20 mg daily, lisinopril 20 mg daily, hydrochlorothiazide 25 mg daily, cyclobenzaprine 10 mg PRN, sumatriptan succinate 100 mg as needed (PRN), loratadine 10 mg daily, estradiol 10 mcg twice a week, rivaroxaban 10 mg daily, acetaminophen 500 mg three times a day, oxycodone 5 mg PRN, tramadol 50 mg PRN and cefuroxime 500 mg twice a day. The Drug Regimen Review section dated 10/16/2025 revealed the following: a. “Potential drug reactions or adverse effects” was marked “Y” (yes). b. “Potential or actual ineffective drug therapy” was marked “Y”. c. “Significant side effects” was marked “Y”. d. “Significant drug interactions” was marked “Y”. e. “Duplicate drug therapy” was marked “Y”. The comment section included instructions to document and describe for any “Y” answers. The comment section documented “Verbalized understanding.” There was no description of the potential drug reactions or adverse effects, ineffective drug therapy, side effects, drug interactions, or duplicate drug therapy and there is no indication the physician was notified. P5’s medication profile dated 03/28/2025 revealed the patient was taking rivaroxaban 10 mg daily hold aspirin until rivaroxaban complete, aspirin 325 mg twice daily hold until rivaroxaban complete, docusate 100 mg twice daily, promethazine 25 mg every six hours as needed (PRN), gabapentin 300 mg every 8 hours PRN, oxycodone-acetaminophen 10-325 mg take one to two tabs every six hours PRN, rosuvastatin 5 mg daily, and losartan 50 mg daily. The Drug Regimen Review section dated 03/28/2025 revealed only “Significant drug interactions” marked as “Y”. The comment section documented all meds reconciled by skilled nursing (SN) upon admission. Indications obtained from MD (Medical Doctor) orders per hospital discharge paperwork. MD aware of all potential duplicate therapies and/or med interactions, as well as holding aspirin until Xarelto [rivaroxaban] completed. P6’s medication profile dated 02/06/2026 revealed the patient was taking metformin 1000 mg twice daily, lisinopril 20 mg daily, tramadol 50 mg three times per day, glipizide 10 mg every morning, simvastatin 20 mg every morning, omeprazole 40 mg every morning, gabapentin 800 mg three times a day, pioglitazone 45 mg daily, multi-vitamin daily, turmeric 500 mg daily, B complex-folic acid daily, and alpha-lipoic acid 200 mg daily. The Drug Regimen Review section dated 02/02/2026 revealed the following: a. “Potential drug reactions or adverse effects” was marked “Y” (yes). b. “Potential or actual ineffective drug therapy” was marked “Y”. c. “Significant side effects” was marked “Y”. d. “Significant drug interactions” was marked “Y”. e. “Duplicate drug therapy” was marked “Y”. The comment section was blank and there were no explanation of the “Y” responses and no indication the physician was notified. P7’s medication profile dated 02/15/2026 revealed the patient was taking sacubitril-valsartan 24-26 mg one-half tab twice per day, alendronate sodium 70 mg weekly, ranolazine 500 mg at bedtime, carvedilol 3.125 mg twice per day, aspirin 81 mg at bedtime, vitamin C 250 mg twice daily, cholecalciferol 1.25 mg weekly, cyanocobalamin 1000 mcg take two and one half tabs daily, fludrocortisone 0.1 mg take two tabs daily, mirtazapine 15 mg at bedtime, famotidine 20 mg daily, torsemide 20 mg take one half tab in the morning, pravastatin 20 mg daily, ferrous sulfate 325 mg daily, tiotropium bromide monohydrate 2.5 mcg two puffs daily, and potassium chloride 10 mEq daily. The Drug Regimen Review dated 02/10/2026 revealed the following: a. “Potential drug reactions or adverse effects” was marked “Y” (yes). b. “Potential or actual ineffective drug therapy” was marked “Y”. c. “Significant side effects” was marked “Y”. d. “Significant drug interactions” was marked “Y”. e. “Duplicate drug therapy” was marked “Y”. The comment section included instructions to document and describe for any “Y” answers. The comment section documented “MD/PA Physician Assistant aware of duplications and/or interactions as it pertains to medication profile. MD/PA aware of duplicate therapies and/or interactions. DC paperwork used as indicator.” There was no documentation of what, if any, adverse effects, ineffective drug therapy, side effects, or drug interactions P7 might have experienced. P8’s medication profile dated 01/13/2026 revealed the patient was taking metoprolol 100 mg take one and one half tab daily, milk of magnesia 400 mg/5 milliliters (ml) take 30 ml as needed (PRN), amlodipine 5 mg twice daily, aspirin 81 mg daily, fleets enema PRN, tamsulosin 0.4 mg daily, bisacodyl 10 mg suppository PRN, ferrous sulfate 325 mg daily, acetaminophen 325 take two tabs daily, sertraline 50 mg daily, finasteride 5 mg daily, omeprazole 20 mg daily, multi-vitamin daily, probiotic daily, docusate 100 mg twice daily, nystatin twice daily to rash, ibuprofen 200 mg one to two tabs every six hours PRN, furosemide 40 mg daily, and potassium 20 mEq daily. The Regimen Review section dated 01/12/2026 revealed the following: a. “Potential drug reactions or adverse effects” was marked “Y” (yes). b. “Potential or actual ineffective drug therapy” was marked “Y”. c. “Significant side effects” was marked “Y”. d. “Significant drug interactions” was marked “Y”. e. “Duplicate drug therapy” was marked “Y”. The comment section included instructions to document and describe for any “Y” answers. The comment section documented “MD/PA aware of duplicate therapies and/or interactions. DC paperwork used as indicator.” There was no documentation of what, if any, adverse effects, ineffective drug therapy, side effects, or drug interactions P8 might have experienced, or the physician was notified of any issues that may have been identified based on the medication reconciliation and patient assessment. P10’s medication profile dated 02/13/2026 revealed the patient was taking allopurinol 100 mg daily, apixaban 5 mg daily, gabapentin 100 mg at bedtime, levothyroxine 75 mg daily, levothyroxine 50 mg daily, ipratropium-albuterol 0.5-2.5 mg/3 ml 2 puffs twice daily, tea tree oil on toenails twice daily, hydrocodone-acetaminophen 5-325 mg every 4 hours as needed (PRN), milk of magnesia 15 ml three times a day PRN, benzonatate 100 mg every 8 hours PRN, loperamide 2 mg every 4 hours PRN, sennosides 2 tabs PRN at bedtime, pantoprazole 40 mg PRN, benzonatate 100 mg every 8 hours PRN, loperamide 2 mg every 4 hours PRN, sennosides 2 tabs PRN at bedtime, pantoprazole 40 mg PRN. The Drug Regimen Review dated 02/13/2026 revealed the following: a. “Potential drug reactions or adverse effects” was marked “Y” (yes). b. “Potential or actual ineffective drug therapy” was marked “Y”. c. “Significant side effects” was marked “Y”. d. “Significant drug interactions” was marked “Y”. e. “Duplicate drug therapy” was marked “Y”. The comment section included instructions to document and describe for any “Y” answers. The comment section documented “MD/PA aware of duplicate therapies and/or interactions. DC paperwork used as indicator.” There is no documentation of what, if any, adverse effects, ineffective drug therapy, side effects, or drug interactions P10 might have experienced, or the physician was notified of any issues that may have been identified based on the medication reconciliation and patient assessment. P11’s medication profile dated 03/05/2026, revealed the patient was taking docusate 100 mg twice daily, acetaminophen 500 mg every eight hours, aspirin 81 mg twice daily, celecoxib 200 mg twice daily, cefuroxime 500 mg twice daily, tranexamic acid 650 mg twice daily, pregabalin 50 mg twice daily, suzetrigine 50 mg every 12 hours, oxycodone 5 mg every 4 hours as needed, donepezil 10 mg daily, and bupropion 300 mg daily. The Drug Regimen Review dated revealed the following: a. “Potential drug reactions or adverse effects” was marked “Y” (yes). b. “Potential or actual ineffective drug therapy” was marked “Y”. c. “Significant side effects” was marked “Y”. d. “Significant drug interactions” was marked “Y”. e. “Duplicate drug therapy” was marked “Y”. The comment section included instructions to document and describe for any “Y” answers. There is no indication of what, if any, adverse reactions or side effects P11 might have experienced. P12’s medication profile dated 01/21/2026 revealed the patient was taking allopurinol 100 mg take one half tab daily, glipizide 5 mg twice daily, alendronate 70 mg daily, amiodarone 200 mg daily, clopidogrel 75 mg daily, empagliflozin 10 mg daily, enzalutamide 80 mg take two tabs daily, metoprolol 25 mg daily, rosuvastatin 20 mg daily, sacubitril 49-51 mg twice daily, and spironolactone 25 mg daily. The Drug Regimen Review revealed the following: a. “Potential drug reactions or adverse effects” was marked “Y” (yes). b. “Potential or actual ineffective drug therapy” was marked “Y”. c. “Significant side effects” was marked “Y”. d. “Significant drug interactions” was marked “Y”. e. “Duplicate drug therapy” was marked “Y”. The comment section included instructions to document and describe for any “Y” answers. P12’s revealed a date of 01/21/26 and “Verbalized understanding.” There was no documentation of what, if any adverse effects, ineffective therapy, side effects or duplicate drug therapy P12 might have experienced and no indication the physician was notified. P13’s medication profile dated 03/01/2026 revealed the patient was taking amlodipine 2.5 mg daily, mirabegron 50 mg daily, ibuprofen 800 mg three times a day as needed (PRN), timolol ophthalmic 0.5% three times a day PRN, and linaclotide 145 mg daily. The Drug Regimen Review revealed the following: a. “Potential drug reactions or adverse effects” was marked “Y” (yes). b. “Potential or actual ineffective drug therapy” was marked “Y”. c. “Significant side effects” was marked “Y”. d. “Significant drug interactions” was marked “Y”. e. “Duplicate drug therapy” was marked “Y”. The comment section included instructions to document and describe for any “Y” answers. The comment section documented “Verbalized understanding” and indicated “MD was notified of current interactions and is aware.” There was no documentation of a description for the “Y” answers regarding side effects or adverse reactions. On 03/11/2026 at 9:25 AM, Registered Nurse (RN)1 stated, “We answer yes to all the questions because all medications have the potential for drug reactions, ineffective therapy, or side effects. In the computer we can click, and it will generate a list of all the potential drug interactions. The doctors know the medications the patient is taking because we get the list from the hospital discharge or the referral.” On 03/11/26 at 3:15 PM, the Administrator confirmed the nurses completing the Medication Review on admission should have answered “Y” to “Potential drug reactions or adverse effects, Potential or actual ineffective drug therapy, Significant side effects, Significant drug interactions,” and “Duplicate drug therapy.” The Administrator stated, “We train when hired to do the assessment and document findings.” The Administrator confirmed the practitioner should have been notified of any findings identified during the review. The agency’s policy titled, “Medication Profile” dated November 2020 revealed, the review would identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy. Any conclusions and findings of patient medication use, or monitoring should be communicated to the pharmacist, when appropriate and other clinicians.””