Summit Home Health Care

“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 (Outcome and Assessment Information Set) assessments within 30 days of completions in January, February, March and April of 2025. This failure prevented the patient’s data from being made available to Center for Medicare and Medicaid (CMS) for analysis to identify agency performance levels in the provision of patient care. Findings included: Record review of the CMS system- IQIES, “Home Health Error Summary by Agency” report generated from the CMS national data system during presurvey preparation on 08/04/2025 revealed Agency had submitted and processed 541 assessments. The report also revealed the agency had 179 assessments with error -3330 indicating those records were submitted after the 30th date of the M0090 date, which equaled to 33.09% of the total assessments submitted with error -3330. Record review of the Agency OASIS Final Validation reports for January 2025 revealed 1 report was processed with error -3330, indicating that assessment was submitted after the 30th date of theM0090 date. Record review of the Agency OASIS Final Validation reports for February 2025 revealed 9 reports were processed with error -3330, indicating that assessments were submitted after the 30th date of the M0090 date. Record review of the Agency OASIS Final Validation reports for March 2025 revealed 1 report was processed with error -3330, indicating that assessment was submitted after the 30th date of the M0090 date. Record review of the Agency OASIS Final Validation reports for April 2025 revealed 4 reports were processed with error -3330, indicating that assessments were submitted after the 30th date of the M0090 date. During an interview on 08/07/2025 at 4:48 p.m., the Administrator and Alternate Administrator/Director of Nursing, stated that the Director of Revenue Cycle Management was responsible for submitting the OASIS reports to CMS once the assessments were completed by clinicians. They further stated the negative impact would be that the plans of care would be delayed or not available as the assessment (OASIS) drives the plan of care for the patient. They further stated the negative impact would include the agency being out of compliance with policies and procedures as well as with the Conditions of Participation set forth by CMS. Review of the agency policy titled “Section 8: Outcome and Assessment Information Set (OASIS)” with a review date of 070125 revealed in part: “OASIS data must be collected and transmitted on the following patients/clients in a Medicare certified agency, regardless of payer: Patients/clients 18 years or older, Non-maternity patients/clients, Excludes patients/clients receiving only homemaker or chore services.…The agency is required to submit all OASIS assessments to the national database specified by CMS within 30 days of M0090 date…””

“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 and interview, the agency failed to ensure clinical staff conducted a current review of all medications the patient was currently using for 1 of 7 patients (Patient #1) whose records were reviewed. This failure prevented the agency from identifying any potential adverse effects and drug interactions that could place patients at risk for negative outcomes. The findings included: During observation with Patient #1 during a home visit which occurred on 08/06/2025 at 9:40 a.m., Patient #1 was observed wearing a nasal cannula (a thin flexible tube that goes around the head and into the nose which has two prongs that go inside the nostrils to deliver oxygen) which was delivering Oxygen at 4 liters per minute which was confirmed by the Registered Nurse C who was conducting the visit when she stated, “your Oxygen saturation level is at 94 % on oxygen at 4 liters per minute.” Per patient, she was to receive Oxygen at 4 liters per minute every night to help with Sleep Apnea (a sleep disorder in which breathing repeatedly stops and starts). Review of Patient #1’s clinical record included a Plan of Care (POC) for the certification period of 07/21/2025 to 09/18/2025 that listed diagnoses of Quadriplegia (a paralysis that affects the ability to voluntarily move the upper and lower body) and Obstructive Sleep Apnea (intermittent airflow blockage during sleep). The POC also listed a skilled nurse (SN) visit frequency of twice a week for one week and once a week for eight weeks effective on week of 07/21/2025. Further review of the clinical record included a form titled “Medication profile” with the timeframe of 07/21-09/18/2025 which failed to include Oxygen under current medications. During interview on 08/07/2025 at 4:51 p.m., the Alternate Administrator/Director of Nursing, stated that Oxygen should have been listed on the patient’s medication profile, and it was the responsibility of every clinician in the home to make sure that the medication list was accurate. She further stated that the negative impact would be that oxygen safety information/teaching would not be provided as the staff would not be aware that patient was on oxygen which would place the patient in danger if Oxygen precautions such as no smoking were not followed. The Alternate Administrator/Director of Nursing further stated the negative impact would also include the primary care physician who signed the plan of care not being aware that patient was receiving oxygen therapy if they were not the prescribing physician. Review of the agency policy titled “Medication List and Monitoring” with a review date of 091524 revealed in part: “I. The agency will maintain a current, accurate list of all prescription and over the counter (OTC) medications taken by the patient/client (Medication Profile). Oxygen therapy including liters per minute, route and frequency will be documented on the medication profile. Professional clinical staff will update the medication list with any change in the medication regimen…””