Anew Healthcare 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 and interview, the agency failed to transmit completed OASIS assessments (Outcome and Assessment Information Set - used to collect patient information to measure outcomes and quality improvement) within 30 days of completing the OASIS assessments to the Centers for Medicare & Medicaid Services (CMS) system for 123 of 318 OASIS assessments transmitted between 9/1/2023 to 8/31/2024. The failure made the agency’s data unavailable to the Centers for Medicare & Medicaid Services to evaluate the agency’s provision of patient care. Review of the Centers for Medicare and Medicaid Services (CMS) OASIS-E (Outcome and Assessment Information Set - tool used by CMS to collect patient information to measure outcomes and quality improvement) Guidance Manual, updated 1,1,2024, read in part; “Chapter 1: OASIS Guidance Manual Introduction…1.5.5.1 General OASIS Item Conventions…14…M0090- Date Assessment Completed, is the last date that information used to complete the comprehensive assessment and determine OASIS coding was gathered by the assessing clinician and documentation of the specific information/responses was completed…” Review of the “OASIS Error Detail Report” taken from the Internet Quality Improvement and Evaluation System (IQIES) on 9/30/2024 indicated that 123 assessments contained the error number -3330, which indicated that the OASIS Assessments were submitted more than 30 days after the assessment completion date between 9/1/2023 and 8/31/2024. Review of the agency’s “OASIS Agency Final Validation” report taken from the Internet Quality Improvement and Evaluation System on 9/30/2024 indicated that the agency submitted 318 OASIS assessments between 9/1/2023 to 8/31/2024. During an interview on 10/1/2024 at approximately 3:07 p.m. with the Agency Owner, Administrator, and the Office Manager, the surveyor discussed the OASIS Error Detail Report. The surveyor discussed that the report indicated that the agency had 123 OASIS assessments that were transmitted to the CMS system more than 30 days after the assessments had been completed. The surveyor asked why the OASIS assessment transmissions were late. The Agency Owner, Administrator, and Office Manager informed the surveyor that it was due to the agency staff not turning in their assessments. The surveyor asked who was responsible to make sure that the OASIS Assessments were turned in by staff. The Administrator informed the surveyor that the Administrator and Director of Nursing would be the ones responsible. The surveyor asked how much leeway the staff had to turn in their assessments. The Administrator stated 72 hours to the fourth day to turn them in. The Administrator stated, “We are hounding them every day.” The surveyor asked what actions the agency took when it was identified that staff were not turning in the assessments within the agency’s time-frame. The Administrator informed the surveyor that the staff were given “verbal and written warnings, then we would no longer utilize them.” Review of the agency’s policy titled “Timelines,” labeled IM.7, and dated 8/1/2020. The policy read in part; “Purpose To establish timely parameters for all medical record information. Policy The Agency will ensure timely provision of care and services to meet the patient’s/client’s needs in compliance with all federal and state laws and regulations...Procedure...II. All completed and encoded OASIS data which accurately reflects the patient’s/client’s status at the time of the assessment, will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set and the CMS-assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with the Federal Information Processing Standard (FIPS 140-2, issued May 25, 2001) from the Agency or the Agency contractor to the CMS collection site within thirty (30) days of the M0090 date...””

“At discharge CFR(s): 484.55(d)(3) At discharge. This Element is not met as evidenced by: Based on record review and interview, the agency failed to complete discharge comprehensive assessments with Outcome Assessment and Information Set (OASIS) at discharge (#4, #6, #11) or the Discharge Comprehensive Assessment with OASIS had been completed by a Licensed Vocational Nurse (#1) for 4 of 7 discharged Licensed and Certified patient records reviewed. The agency failed to evaluate the patients’ needs and progress when the patients were leaving home health services and failed to provide information to the Center for Medicare and Medicaid Services of the patients’ conditions upon discharge from the agency. Review of the “Outcome and Assessment Information Set OASIS-E Manual,” updated January 1, 2024. The manual read in part; “...1.5.4 Who Completes OASIS? As identified in (M0080) Discipline of Person Completing Assessment, the comprehensive assessment including OASIS data collection, if applicable, is the responsibility of a registered nurse (RN) or any of the therapies, including physical therapist (PT), speech language pathologist/speech therapist (SLP/ST), or occupational therapist (OT). A licensed practical nurse or licensed vocational nurse (LPN/LVN), physical therapist assistant (PTA), occupational therapy assistant (OTA), medical social worker (MSW), or home health aide may not be responsible for completing the comprehensive assessment and OASIS...” Patient #1: Record review of Patient #1’s clinical record revealed a Plan of Care dated 3/15/2023 to 5/13/2023. The Plan of Care indicated that Patient #1 started on the agency’s services on 3/15/2023. The Plan of Care listed Hemiplegia following Cerebral Infraction affecting Left Nondominant Side (stroke - paralysis and weakness with the loss of the ability to move part of the body) as the primary diagnosis. Patient #1’s clinical record contained a Start of Care Comprehensive Assessment which indicated that Patient #1’s current payment source for home care was Medicare. Patient #1’s record contained a communication note that Patient #1’s insurance was out of network and Patient #1 was transferred to another agency. Patient #1’s record contained an OASIS-E Discharge dated 4/12/2023 by Licensed Vocational Nurse G. Licensed Vocational Nurse G documented that Patient #1’s current payment source for home care was Medicare. Patient #4: Record review of Patient #4’s clinical record revealed documentation of a Start of Care Comprehensive Assessment dated 6/2/2024. The Start of Care Comprehensive assessment indicated that Patient #4 started on the agency’s services on 6/2/2024. The Start of Care Comprehensive assessment listed Essential Hypertension (high blood pressure) as the primary diagnosis. The Start of Care Comprehensive Assessment indicated that Patient #4’s current payment source for home care was Medicare. Patient #4’s Episode Manager indicated that Physical Therapy Assistant H conducted the last skilled visit on 7/23/2024. Patient #4’s clinical record contained no evidence that a Discharge Comprehensive Assessment with OASIS was done. Patient #6: Record review of Patient #6’s record revealed a Plan of Care dated 5/15/2024 to 7/13/2024. The Plan of Care indicated that Patient #6 was admitted to the agency on 5/15/2024. The Plan of Care listed Essential Hypertension (high blood pressure) as the primary diagnosis. Patient #6’s clinical record contained documentation of a Recertification Comprehensive Assessment dated 7/13/2024. The Recertification Comprehensive Assessment was signed by Registered Nurse E. Registered Nurse E documented that a skilled nurse would conduct visits once a week for 9 weeks. The Recertification Comprehensive Assessment indicated that Patient #6’s current payment source for home care was Medicare. Patient #6’s Episode Manager indicated that Licensed Vocational Nurse F conducted the last skilled visit on 7/24/2024. Patient #6’s clinical record did not contain evidence that a Discharge Comprehensive Assessment with OASIS was done. Patient #11: Record review of Patient #11’s clinical record revealed a Plan of Care dated 7/3/2024 to 8/31/2024. The Plan of Care indicated that Patient #11 started on the agency’s services on 7/3/2024. The Plan of Care listed Essential (primary) Hypertension (high blood pressure) as the primary diagnosis. Patient #11’s clinical record contained a Start of Care Comprehensive Assessment conducted on 7/3/2024. The Start of Care Comprehensive Assessment indicated that Patient #11’s current payment source for home care was Medicare. Patient #11’s Episode Manager indicated that Licensed Vocational Nurse F conducted the last skilled visit on 7/24/2024. Patient #11’s clinical record did not contain evidence that a Discharge Comprehensive Assessment with OASIS had been done. During an interview on 10/4/2024 at 12:37 with the Administrator and Supervising Nurse, the surveyor discussed that there was no evidence that Discharge Comprehensive Assessments were not done or were done by a Licensed Vocational Nurse for the 4 patients referenced. The Supervising Nurse informed the surveyor that the Discharged Comprehensive Assessments with OASIS would need to be done by a Registered Nurse. The surveyor asked why a Licensed Vocational Nurse completed the Discharge Comprehensive Assessment with OASIS for Patient #1. The Supervising Nurse stated, “Would have to get with [Office Manager].” The Office Manager did the scheduling. The surveyor asked why the Discharge Comprehensive Assessments with OASIS were not done. The Supervising Nurse stated, “Don’t know what happened.” The Administrator and Supervising Nurse did not dispute that the Discharge Comprehensive Assessments with OASIS were not done and that one had been completed by a Licensed Vocational Nurse. During an interview on 10/4/2024 at approximately 2:45 p.m. with the Administrator and the Office Manager, the Administrator informed the surveyor that the Office Manager had only been in that position for 4-5 months. The Office Manager was not in the position in 2023, when the Licensed Vocational Nurse conducted a Discharge Comprehensive Assessment with OASIS. Licensed Vocational Nurse F, Licensed Vocational Nurse G, and Physical Therapy Assistant H were not employed with the agency at the time of the survey.”

“Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This Element is not met as evidenced by: Based on record review and interview, the clinical manager failed to develop an initial plan of care (#4) and failed to develop an updated individualized Plan of Care (#6) for 2 of 7 discharged Licensed and Certified patient records reviewed. The failure placed the patients’ safety at risk and at risk to receive inappropriate care that could result in worsening of the patients’ health status. Agency had electronic medical records. Patient #4: Record review of Patient #4’s clinical record revealed documentation of a Start of Care Comprehensive Assessment dated 6/2/2024. The Start of Care Comprehensive assessment indicated that a Registered Nurse completed the assessment. The Start of Care Comprehensive assessment listed Essential Hypertension (high blood pressure) was listed as the primary diagnosis. The Start of Care Comprehensive assessment was not signed by the registered nurse, but the visit was scheduled to Registered Nurse E. Patient #4’s clinical record did not contain a plan of care. Patient #6: Record review of Patient #6’s record revealed a Plan of Care dated 5/15/2024 to 7/13/2024. The Plan of Care indicated that Patient #6 was admitted to the agency on 5/15/1/2024. The Plan of Care listed Essential Hypertension (high blood pressure) as the primary diagnosis. Patient #6’s clinical record contained documentation of a Recertification Comprehensive Assessment dated 7/13/2024. The Recertification Comprehensive Assessment was signed by Registered Nurse E. Registered Nurse E documented that a skilled nurse would conduct visits once a week for 9 weeks. Patient #6’s clinical record did not contain an updated Plan of Care for the 60-day episode of care beginning 7/14/2024 through 9/11/2024. Licensed Vocation Nurse F conducted skilled nurse visits on 7/17/2024 and 7/24/2024. During an interview on 10/4/2024 at 12:37 p.m. with the Administrator and Supervising Nurse, the surveyor discussed that Patient #4 and Patient #6 did not have Plans of Care. The Supervising Nurse confirmed that Patient #4 and Patient #6 did not have a Plan of Care, stating “Don’t see a Plan of Care.” The surveyor asked who would be responsible to develop the Plans of Care. The Supervising Nurse stated, “The Registered Nurse that did the admission/recertification would develop/update the Plan of Care.” The surveyor asked would that be Registered Nurse E, the registered nurse that conducted the Start of Care Comprehensive assessment and Recertification assessment. The Supervising Nurse stated, “Yes.” The surveyor asked who tracked to make sure that the Plans of Care were developed. The Supervising Nurse informed the surveyor that the Office Manager would be the one to track the Plans of Care. During an interview on 10/4/2024 at 3:04 p.m. with the Owner and Administrator, the surveyor asked how the findings could affect the agency’s patients. The Administrator stated, “Could affect safety.” Registered Nurse E was not employed with the agency at the time of the survey. Review of the agency’s policy titled “Plan of Care,” labeled PC.8, and dated 11/1/2020. The policy read in part; “Purpose To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems...Policy...Procedure I. The appropriate licensed professional staff member, with physician and/or non-physician practitioner participations, is responsible for developing the plan of care within three (3) to five (5) days of the initial assessment. A. A Registered Nurse initiates the plan of care for skilled nursing care...VI. The individualized plan of care must be reviewed and revised by the physician...no less frequently than once every 60 days, beginning with the start of care date...””