Incare Home Health Northern Ohio

“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, policy review, and staff interview, the agency failed to ensure all Outcome and Assessment Information Set (OASIS) reports were submitted within 30 days of completion. This could potentially affect all patients receiving care from the agency. The census was 125. Review of the OASIS Submission binder for 2025 revealed 11 out of 11 submitted reports reviewed were submitted more than 30 days after the M0090, completion date, and all received the error M3330. Interview on 02/18/25 at 10:46 AM Staff A confirmed the late submissions. Review of the undated agency policy titled “OASIS Data for Medicare Certified Home Health Agencies” revealed the agency must encode and transmit OASIS data for each patient within 30 days of competing an OASIS data set.”

“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 policy review, record review, and staff interview, the agency failed to ensure the orders on the plan of care were followed for one patient (Patient #3). This could potentially affect all patients receiving care from the agency. The census was 125. Review of the medical record for Patient #3 and review of the physician’s plan of care dated 01/25/25 to 03/25/25 revealed Calcium Alginate was to be applied to the patient’s wound daily. There was no documented evidence this was done daily. Interview on 02/19/25 at 9:03 AM, Licensed Practical Nurse (LPN) Staff C stated they apply the Calcium Alginate on Monday, Wednesday and Friday. Staff C stated the caregiver does it the other four days per week. Additional review of the medical record for Patient #3 did not reveal documentation the skilled nurse provided education to the care giver with a return demonstration on how to apply the Calcium Alginate and do the dressing change. There was no documentation about who the caregiver was or if the care giver was available four days per week to change the dressing. Interview on 02/20/25 at 9:56 AM Staff A confirmed there was no documentation the caregiver was available and trained on how to do the dressing change four days per week. Review of the undated agency policy titled “5.17 Care Follows the Plan of Care” revealed the agency is responsible to provide evidence in the patient record that care is delivered in accordance with the plan of care.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observations, policy review, staff interview, and record review, the agency failed to ensure signed physician’s order was obtained for all services provided for one patient (Patient #3). This could potentially affect all patients receiving care from the agency. The census was 125. Observation on 02/19/25 at 9:00 AM of a home visit for Patient #3 revealed Licensed Practical Nurse (LPN) Staff C, was observed to cleanse the open wound on the patient’s left leg with normal saline, apply Calcium Alginate and ABD pad, and wrapped with gauze. Review of the medical record for Patient #3 and the physician’s plan of care dated 01/25/25 to 03/25/25 did not reveal a signed physician’s order for the skilled nurse to do wound care. Review of the undated agenc policy titled “5.22 Verbal Orders” revealed physician’s orders, which are signed, timed and dated by the physician, are required for all services rendered by the agency. Interview on 02/19/25 at 1:36 PM Staff B confirmed there was no physician’s order for the skilled nurse to do wound care.”

“Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient’s discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner’s issuing orders for the HHA plan of care, and the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any). This Element is not met as evidenced by: Based on record review, policy review, and staff interview the agency failed to ensure the physician was notified of the patient’s discharge. This could potentially affect all patients receiving care from the agency. The census was 125. Review of the medical record for Patient #7 revealed a discharge summary with a discharge date of 01/23/25. There was no documented evidence the physician had been notified of the patient’s discharge or of the discharge summary. Interview on 02/18/25 at 1:38 PM Staff A confirmed there was no documentation the physician had been notified. Review of the undated agency policy titled “Transfer and Discharge Policy” revealed a discharge summary note is written, and a copy is sent to the physician, within five days. The physician is also notified of discharge by phone call to the office or by fax.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on observations, policy review, record review, and staff interview, the agency failed to ensure wound measurements were done weekly per policy. This affected one (Patient #3) out of three patients reviewed with an open wound. The census was 125. Review of the medical record for Patient #3 and the physician’s plan of care dated 01/25/25 to 03/25/25 revealed the skilled nurse was to conduct a visit three times a week. The patient had a chronic venous ulcer. Under medications sterile water was listed for irrigation three times a week and Calcium Alginate externally every day. The record and the visit sheets dated 02/03/25, 02/05/25, 02/07/25, 02/10/25, 02/12/25 and 02/14/25 did not reveal any wound measurements. Observation on 02/19/25 at 9:00 AM during a home visit for Patient #3 with Licensed Practical Nurse (LPN) Staff C, Staff C was observed to do wound care to the open wound on Patient #3’s left leg and change the wound dressing. No wound measurements were observed to be obtained. Interview on 02/19/25 at 12:28 PM Staff B confirmed there were no wound measurements for the two weeks reviewed. Review of the agency policy titled “Wound Assessment and Documentation” revealed documentation on the visit report should include wound measurements at least weekly, including the length, depth and width of the wound in centimeters.”