Enhabit Home Health of Southeast Oklahoma

“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 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 OASIS Error Summary Report for the year 01/01/2024 to 12/31/2024 showed a total of 33 Late Submission Error -3330 Warning messages for 1.11% error rate. During an interview on 06/02/25 at 2:15 PM, Staff A stated the Agency began a new review process in January 2025 and this new process has resulted in a higher error rate for late submissions. Review of an agency HHA Error Summary Report provided by Staff A for the previous year of 06/02/2024 - 06/02/2025 showed 119 Warning Messages for Late Submission for a total 3.59% error rate. A second review of the Current Year-To Date 01/01/2025 - 05/31/2025 showed 99 Warning Messages for a total 6.66% error rate. During an interview on 06/02/25 at 3:00 PM, Staff A stated Agency’s failure to submit assessments after completion within the required 30-day period.”

“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 and interview, the agency failed to ensure the RN conducted onsite Supervisory Aide Visits (SAV) at least every 14 days for three (#1, #6 and #12) of five (#1, #3, #5, #6 and #12) patients records reviewed with orders for Home Health Aide (HHA) services. Patient #1 A review of the POC for Patient #1 for recertification period 04/13/25 to 06/11/25 showed a Primary Diagnosis of Urinary Tract Infection and orders for HHA services two time a week for eight weeks and one time a week for one week. Review of HHA Visit notes showed HHA visit were conducted weekly as ordered. Further review of SN Visit notes for the same time period showed the RN conducted a SAV on 05/06/25 and next on 05/21/25 (1 day late). Patient #6 A review of the POC for Patient #6 for recertification period 05/14/25 to 07/12/25 showed a Primary Diagnosis of Pressure Ulcer to Right and Left Heels and orders for HHA services one time a week for one week and two times a week for eight weeks. Review of HHA Visit notes showed HHA visit were conducted weekly as ordered. Further review of SN Visit notes for the same time period showed the RN conducted a SAV on 05/12/25 and next on 06/02/25 (7 days late). Patient #12 A review of the POC for Patient #12 for recertification periods 03/29/25 to 05/27/22 and 05/28/25 to 07/26/25 showed a Primary Diagnosis of Chronic Kidney Disease with Heart Failure and orders for HHA services one time a week for nine weeks. Review of HHA Visit notes showed HHA visit were conducted weekly as ordered. Further review of SN Visit notes for the same time period showed the RN conducted a SAV on 04/08/25 and next on 04/24/25 (2 days late), 05/06/25, 05/20/25 and no SAV was documented when due on 06/03/25. During an interview on 06/04/25 at 2:45 PM, Staff A stated the Supervisory Visits were not completed timely for patients #1, #6 and #12.”

“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 send a completed transfer summary to the facility within 2 business days for one (#17) of two (#15 and #17) records reviewed for patients transferred to short term general hospitals. Patient #17 Record review for certification period 03/03/25 to 05/04/25 showed a Primary Diagnosis of Pressure Ulcer to Sacral Region and included a 04/23/25 Client Coordination Note titled “Hospital Hold” and Transfer Summary with documentation the patient was transferred to a local hospital due to Sepsis on 04/22/25. Further record review failed to provide evidence the Transfer Summary was sent to the facility. During an interview on 06/04/25 at 2:45 PM, Staff A stated a Transfer Summary was not sent to the facility for patient #17.”