Angels Care Home Health VII

“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 administrative record review and interview, the Agency failed to transmit completed Outcome and Assessment Information Set (OASIS) assessment to the CMS system within the required 30 days. Pre-survey review of HHA Error Summary Report for the year 08/26/2024 to 08/26/2025 showed a total of 37 Late Submission Error -3330 Warning messages for a 4.38% error rate. Review of an agency HHA Error Summary Report provided by Staff B for the previous month of 07/26/2025 - 08/26/2025 showed 2 Warning Messages for Late Submission for a total 3.08% error rate. During an interview on 08/27/25 at 2:15 PM, Staff B stated the Agency failed to submit assessments after completion within the required 30-day period.”

“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, observation and interview, the agency failed to conduct a review of all medications the patient was currently using to identify adverse effects and drug reactions, side effects, and duplicate drug therapy for three (#2, #3, and #6) of seven (#1- #7) records reviewed. Pt #2 Review of the POC for ROC period 08/05/25 - 08/30/25 showed a diagnosis of Type II Diabetes Mellitus with Peripheral Angiopathy without Gangrene and orders for SN to provide wound care to Left Groin 3 times a week for 4 weeks and 2 PRN visits. Further review of the form titled, “Client Medication Profile” showed Pt #2 was to receive 60 Units of Insulin Glargine (U-100) at bedtime. On 08/27/25 at 12:45 PM, SN3 was observed conducting a medication profile review: Upon opening the refrigerator to confirm the Glargine Insulin dosage, SN3 identified additional Regular Insulin. When Pt#2 was questioned regarding her use of the Regular Insulin, she stated she has been on that insulin for 1 or 2 years. SN3 confirmed the Regular Insulin was not listed on the Client Medication Profile since SOC on 07/02/25 and confirmed with the physician Pt#2 was to take the Regular Insulin on a sliding scale 3 times per day. Pt #3 Review of the POC for recertification period 08/07/25 - 10/05/25 showed a diagnosis of Unspecified Atrial Fibrillation and Hypertensive Heart Failure with orders for SN visits 1 time a week for 8 weeks. On 08/27/25 at 08:45 AM, SN2 conducted a review of the current client medications. A comparison of medications in the home with the Client Medication Profile identified multiple discrepancies for prescription and OTC medication Pt#3 stated she was taking that were not listed on the current medication profile. Documentation showed the medication profile was last reviewed by a SN on 08/04/25. Pt #6 Review of the POC for SOC period 03/28/25 - 05/26/25 showed a diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure with orders for SN visits 1 time a week for 2 weeks. Further review of SOC documentation by the SN on 03/28/25 showed Pt#6 was using Oxygen at 4 liters per nasal cannula intermittently and Oxygen was listed as DME/ Supplies. Review of the Client Medication Profile failed to include Oxygen as identified by the SN. During an interview on 08/27/25 at 2:15 PM, Staff B stated the SN staff failed to review all medications and ensure the agency provided current and accurate medication profiles for Pts #2, #3, and #6.”

“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 record review, observation and interview the SN failed to provide wound care and diabetic foot care as ordered for one (#2) of two (#1 and #2) wound care procedures observed. Pt #2 Review of the POC for ROC period 08/05/25 - 08/30/25 showed a diagnosis of Type II Diabetes Mellitus with Peripheral Angiopathy without Gangrene with orders for SN to instruct/reinforce diabetic care to include diet, skin care, blood glucose testing and diabetic foot care. Wound care orders stated, “SN to perform wound care to Left Groin 3 times weekly. Via aseptic technique, remove old dressing and dispose of in biohazard bag, cleanse wound with SNS [Sterile Normal Saline], pat dry with gauze, apply Medi honey to open area, cover with secondary dressing, secure in place.” Further review of SN documentation as “Care Provided” on the “Wound Care Record” for SN visits 08/07/25 to 08/22/25, failed to show evidence Medi Honey was applied to the wound as ordered for each wound care visit. A subsequent physician order dated 08/26/25 showed orders for SN to provide wound care to Left Groin and Left Great Toe every Monday, Wednesday, Friday unless patient has wound clinic appointment. On 08/27/25 at 12:45 PM, SN3 was observed conducting wound care: Wound care orders for Left Great Toe stated “remove old dressing and dispose of in biohazard bag, cleanse wound and peri wound with Vashe wound cleanser, pat dry with gauze, apply betadine, Aquacel Ag, ABD pad wrap with kerlix, apply foam felt donut and secure with tape using aseptic technique. SN3 removed Pt#2 slipper and completed wound care to the Left Great Toe as ordered. SN3 did not remove the right slipper and conduct a diabetic foot check or discuss diabetic foot care with Pt#2 as ordered. Wound care orders for Left Groin stated “remove old dressing and dispose of in biohazard bag, cleanse wound and peri wound with Vashe wound cleanser, apply Aquacel Ag and cover with Mepilex using aseptic technique. SN3 removed the old dressing and applied betadine directly to the wound which was not ordered. SN3 continued the wound care with Aquacel and Mepilex as ordered. At completion of the SN visit, this Surveyor reviewed the Left Groin wound order with SN3. SN3 confirmed she applied betadine directly to the Left Groin wound which was not ordered. During an interview on 08/27/25 at 02:15 PM, Staff B stated the SN staff did not provide wound care as ordered for Patient #2.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the 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) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to provide a completed transfer summary to the facility and the physician within 2 business days of becoming aware of an unplanned transfer for one (#6) of two (#6 and #7) discharged/ transfer records reviewed. A review of the POC for Patient #6 for SOC certification period 03/28/25 - 05/26/25 showed a transfer to a short-term general hospital on 03/31/25. Further review failed to provide evidence a transfer summary was sent to the facility or physician as required. During an interview on 08/27/25 at 2:15 PM, Staff B stated the agency failed to send a completed transfer summary to the facility or physician within 2 business days of becoming aware of an unplanned transfer for Patient #6.”