Caresense Home Health

“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 review of agency policy, clinical records (CR), ‘OASIS Final Validation Report’ for 2024 and 2025, and interview with the agency Administrator/Director of Nursing, it was determined the agency failed to ensure the transmittal of OASIS data for two (2) of two (2) CR reviewed for patients eighteen (18) years of age with skilled services. (CR#1 and 3). Review of policy “Reporting of OASIS Information” on 12/23/2025 at approximately 3:30 P.M. states “Agency must collect, encode, and transmit OASIS date for: ...Medicaid (traditional and HMO/managed care) patients that are age 18 and over and receiving skilled services ...” Review of an ‘OASIS Final Validation Report’ for 2024 and 2025 on 11/25/2025 at approximately 3:00 P.M. revealed that the last time OASIS information was transmitted by the agency was 9/26/2024. Review of Clinical Records on 12/22/25 from approximately 2:00 PM-3:00 P.M. and 12/23/2025 from approximately 8:30 A.M. to 1:30 P.M. revealed the following: CR#1: Start of care 2/6/2017. Patient is over eighteen years of age and is receiving skilled nursing services from the agency. CR#3, start of care 8/29/2014. Patient is over eighteen years of age and is receiving skilled nursing services from the agency. An interview with the agency Administrator/Director of Nursing on 12/26/2025 at approximately 11:30 A.M. confirmed the above findings.”

“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 a review of agency policy, clinical records (CR), and an interview with the agency Administrator/Director of Nursing, the agency failed to submit timely documentation of skilled nursing visits, and/or document physician notification and obtain a verbal order to amend frequencies for missed visits for three (3) of seven (7) CR reviewed. (CR #1, 2, and 6) Findings include: Review of agency policy ‘Plan of Care – CMS #485 and Physician Orders” on December 23, 2025, at approximately 2:15 P.M. states, “Procedure: 20. Care and services provided will be provided according to physician orders. Orders are current and updated… 26… If CareSense provides fewer visits than the physician orders, it has altered the plan of care and the physician must be notified. CareSense must maintain documentation in the clinical record indicating that the physician was notified and is aware of the missed visit.” Review of agency policy ‘Timely Submission of Patient Documentation’ on December 26, 2025, at approximately 8:15 A.M. states, “Procedure: 2. Itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding three (3) business days. All patient visit reports from contract personnel must be submitted within three (3) business days from the date of the visit, e.g., PT, SLP, etc.” Review of Clinical Records on 12/22/25 from approximately 2:00 PM-3:00 P.M. and 12/23/2025 from approximately 8:30 A.M. to 1:30 P.M. revealed the following: CR #1, start of care 2/6/202. Certification period reviewed, 11/6/2025 through 1/4/2026, contained orders for skilled nursing (SN) 35 to 43 hours per week for 60 days. Week 2, 11/9/2025 – 11/15/2025, 32 hours of SN services were provided. Week 3, 11/16/2025 – 11/22/2025, 24 hours of SN services were provided, Week 4, 11/23/2025 – 11/29/2025, 28 hours of SN services were provided, Week 5, 11/30/2025 – 12/6/2025, 24 hours of SN services were provided, and Week 7, 12/14/2025 – 12/20/2025, 24 hours of SN services were provided. SN visits were documented in the electronic medical record (EMR) as ‘not started’ on 11/16/2025, 11/17/2025, 12/1/2025, 12/6/2025, 12/7/2025, 12/8/2025, 12/10/2025, and 12/11/2025. There was no documentation that the primary physician was notified of the missed visits and no verbal orders to amend the visit frequencies. CR #2, start of care 8/29/2014. Certification period reviewed, 11/8 2025 through 1/6/2026, contained orders for SN 24 hours per day, seven (7) days per week for 60 days. Less than 24 hours per day of SN services were provided on 11/13/2025 (20 hours), 11/15/2025 (12 hours), 11/16/2025 (12 hours), 11/20/2025 (20 hours), 11/22/2025 (12 hours), 11/23/2025 (12 hours), 11/25/2025 (15 hours), 11/27/2025 (17 hours), 11/29/2025 (12 hours), 11/30/2025 (12 hours), 12/4/2025 (20 hours), 12/6/2025 (12 hours), 12/7/2025 (12 hours), 12/11/2025 (20 hours), 12/13/2025 (12 hours), 12/14/2025 (9 hours), 12/15/2025 (16 hours), 12/16/2025 (16 hours), 12/17/2025 (16 hours), 12/18/2025 (12 hours), 12/19/2025 (16 hours), 12/20/2025 (12 hours), and 12/21/2025 (12 hours). SN visits were documented in the EMR as “not started” on 12/17/2025 and 12/18/2025. There was no documentation that the primary physician was notified of the missed visits and no verbal orders to amend the visit frequencies. CR #6, start of care 10/11/2024. Certification period reviewed, 2/8/2025 – 4/8/2025 contained orders for SN 8 hours per night, 7 nights per week for 60 days. There were no services documented from 2/8/2025 – 2/28/2025, when the patient was transferred to another agency. There was no documentation that the primary physician was notified of the missed visits and no verbal orders to amend the visit frequencies. An interview with the agency Administrator/Director of Nursing on 12/26/2025 at approximately 11:30 A.M. confirmed the above findings.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on review of agency policy, clinical records (CR) and staff interviews, the agency failed to ensure that physician orders were signed within the required timeframe for six (6) of seven (7) CR reviewed. (CR #1, 2, 4, 5, 6, and 7). Findings include: Review of agency policy titled ‘Physician Orders – Verbal Orders’ on 12/23/2025 at approximately 2:20 P.M. states, “Procedure: 2. All physician orders should be sent from the office the day they arrive or the day they are prepared (as in the case of CMS Plans of Care)… 4. A tracking file is numbered 1-31, corresponding to the dates of the month. When an order is sent out, a copy of the order is placed in the number ten days after the date the order is written. 5. The tracking file is checked every day and if the there are overdue orders in the file, the physician’s office is called to verify if indeed the order was received and if a second copy needs to be sent… 6. When following up on a late order, document the action taken including the name of the person following up, the date and to whom spoken… 8. If the order has not been returned by the 20th day, a copy is placed in the appropriate file for the Director of Clinical Services (for further action) and the tracking copy is placed in the front of the tracking file…” Review of Clinical Records on 12/22/25 from approximately 2:00 PM-3:00 P.M. and 12/23/2025 from approximately 8:30 A.M. to 1:30 P.M. revealed the following: CR #1, start of care 2/6/2020. Certification period reviewed, 11/6/2025 – 1/4/2026, contained a signed Plan of Care (POC) dated 12/17/2025 (41 days after the start of the certification period). There was no documentation that follow-up was conducted according to agency policy. CR #2, start of care 8/29/2014. Certification period reviewed, 11/8/2025 – 1/6/2026, contained a signed POC dated 12/15/2025 (37 days after the start of the certification period). There was no documentation that follow-up was conducted according to agency policy. CR #4, start of care 1/4/2017. Certification period reviewed, 9/19/2025 – 11/17/2025, contained a signed POC dated 11/5/2025 (59 days after the start of the certification period). There was no documentation that follow-up was conducted according to agency policy. CR #5, start of care 11/26/2023. Certification period reviewed, 1/19/2025 – 3/19/2025, contained a signed POC dated 3/31/2025 (72 days after the start of the certification period). There was no documentation that follow-up was conducted according to agency policy. CR #6, start of care 10/11/2024. Certification period reviewed, 2/8/2025 – 4/8/2025, contained an unsigned POC. There was no documentation that a physician signed the POC and no documentation that follow-up was conducted according to agency policy. CR #7, start of care 3/31/2025. Certification period reviewed, 3/31/2025 – 4/15/2025, contained an unsigned POC. There was no documentation that a physician signed the POC and no documentation that follow-up was conducted according to agency policy. An interview with the agency Administrator/Director of Nursing on 12/26/2025 at approximately 11:30 A.M. confirmed the above findings.”