Abc Health Care 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, interview and policy review the facility failed to submit Outcome and Assessment Information Set (OASIS) assessments within 30 days. This affected three (Patients #1, #6 and #7). This had the potential to affect all patients. Findings include: 1. Record review revealed Patient #1 started care on 02/21/24. The certification period reviewed was for 12/17/24 through 02/14/25. Patient #1 had skilled nursing ordered two times per day to assist with insulin injections. Review of the OASIS submissions revealed the assessment from 12/17/24 was not submitted until 02/14/25 at 12:14 PM. 2. Record review revealed Patient #6 started care on 09/01/23. The certification period reviewed was for 12/24/24-02/21/25. Skilled nurse visits were ordered two times per day to assist with medication administration. Review of the OASIS submissions revealed the assessment from 12/22/24 was not submitted 02/14/25. 3. Record review revealed Patient #7 started care on 09/21/21. The certification period reviewed was for 01/03/25 to 03/03/25. Skilled nursing was ordered two times per day to assist with medication administration. Review of the OASIS submissions revealed the assessment from 12/29/24 was not submitted until 02/14/25. During an interview on 03/06/25 at 3:00 P.M., Staff A stated the OASIS assessments for Patient #1, #6 and #7 were not submitted within 30 days. The facility policy titled “Reassessments/Recertification” stated staff are to complete a comprehensive assessment every sixty days beginning with the SOC. A comprehensive assessment, including all required OASIS data elements, must be performed to measure patient progress towards outcomes. The total plan of care must be renewed at least every 60 days, or more often as warranted. The OASIS assessments for recertification, significant changes in condition, transfer, resumption of care and discharge will be completed within the mandate time frames. The OASIS date will be encoded within seven days of completion and transmitted to the state agency or CMS monthly.”

“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 record review and interview, the failed to ensure the physician ordered plan of care was accurate to reflect the hours of services received and failed to notify the physician when missed visits occurred. This affected one (Patient #4) with the potential to affect all patients. Findings include: Record review revealed Patient #4 started care on 04/27/17. The primary diagnosis was quadriplegia, C1-C4 incomplete. The certification periods reviewed were 09/17/24 through 11/15/24 and 01/15/23 through 03/15/25. Home health aide (HHA) services were ordered for 69.5 hours per week. Review of a case manager note dated 09/17/24 stated beginning on 09/18/24, another agency would be covering the 8:30 AM-4:30 PM hours and the agency would keep the night and weekend staff. The physician ordered plan of care for the certification periods of 11/15/24 through 01/14/25 and 01/15/25 thorough 03/15/25 listed HHA services for 69.5 hours a week. Review of the HHA time sheets revealed the services were provided three hours a day from 10:00 PM to 1:00 AM and four hours during the day on Sunday to equal 25 hours per week. There were no visits provided on Sunday evening. There was no documentation in the medical record the physician had been notified the Sunday visits had not been completed. During an interview on 03/05/24 at 1:45 P.M., Staff A verified the physician ordered plan of care listed 69.5 hours per week and the facility was only providing 25 hours per week. It was also verified the Sunday evening visits were not completed and the physician was not notified.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review, staff interview and policy review, the facility failed to complete recertification assessments within the last five days of every 60 days. This affected one (Patient #1) with the potential to affect all patients cared for by this agency. Findings include: Record review revealed Patient #1 started care on 02/21/24. The certification period reviewed was 02/15/25 through 04/15/25. Review of the recertification assessment revealed it was not completed until 02/27/25. During an interview on 03/06/25 at 3:20 P.M., Staff A verified the recertification assessment was not completed timely. Review of the policy titled “Reassessments/Recertification” stated to complete a comprehensive assessment every sixty days beginning wit the start of care. OASIS assessments should be completed for recertification, transfer, resumption of car and discharge. This OASIS data will be encoded within seven days of completion and transmitted to the state agency or CMS at least monthly. A comprehensive assessment will be completed no earlier than five days before and no later than one day before the calendar day on which the new episode of care began.”

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on record review, interview and policy review, the facility failed to complete the Outcome and Assessment Information Set (OASIS) when a patient was discharged from the agency. This affected one(Patient #7) with the potential to affect all patients. Findings include: Record review revealed Patient #7 started care on 09/21/21. The certification period reviewed was for 01/03/25 through 03/03/25. Skilled nursing was ordered two times per day to assist with medication administration. Review of the medical record revealed the skilled nursing visits were provided as ordered with the last day of service on 01/18/25. During an interview on 03/06/25 at 3:00 P.M., Staff B verified no discharge OASIS has been completed to date. Review of the policy titled “Reassessments/Recertification” stated staff are to complete a comprehensive assessment every sixty days beginning with the SOC. A comprehensive assessment, including all required OASIS data elements, must be performed to measure patient progress towards outcomes. The total plan of care must be renewed at least every 60 days, or more often as warranted. OASIS assessments for recertification, significant changes in condition, transfer, resumption of care and discharge will be completed within the mandate time frames. OASIS date will be encoded within seven days of completion and transmitted to the state agency or CMS monthly.”

“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 record review, interview and policy review, the agency failed to complete supervisory visits for the aide every 14 days when skilled services are being provided. This affected one (Patient #2) with the potential to affect all patients. Findings include: Record review revealed Patient #2 started care on 01/21/25. The certification period reviewed was for 01/21/25 through 03/21/25. Home health aide (HHA) services were ordered six hours per week along with physical therapy (PT) and occupational therapy (OT). The visits were provided as ordered. There was no documentation of a supervisory visit of the HHA every 14 days. During an interview on 03/05/25 at 10:00 A.M., Staff A stated supervisory visits were done every 60 days when they completed the recertification. A supervisory visit was not done every 14 days. Review of the policy titled “Supervision of Clinical Services” stated home health supervision should be conducted every 14 days when skilled services are being provided. Supervision can be completed with the aide present or not.”