Guardian Healthcare

“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 interview and record review, the agency failed to code and electronically transmit each completed OASIS (data collected as part of the comprehensive assessment) assessment to the CMS system within thirty days of completing the assessment of the beneficiary for 400 of 3160 assessments submitted (12.66%). The agency did not code and electronically submit 400 patient’s OASIS data to IQIES (electronic system used to transmit quality measures from the OASIS data collected during comprehensive assessments) within 30 days to track and evaluate changes in the patient’s health while admitted to home health services to help ensure quality healthcare for patients. This failure prevented the agency’s patient OASIS data from being made available to CMS for analysis of patient care performance. Findings included: Review of an IQIES Error Summary Report dated 03/21/24 to 03/21/25 generated by the surveyor during pre-survey on 03/21/25 indicated the agency failed to code and electronically transmit 400 of 3160 OASIS assessments data to the CMS system within thirty days of completing the assessment of the beneficiary. During an interview on 03/24/25 at 1:51 p.m., the RN Alternate Administrator said a corporate person submitted OASIS to IQIES for all locations. She said the office locked OASIS then a report was sent to corporate to send to IQIES. During an interview on 03/24/25 at 2:41 p.m., the RN Alternate Administrator said not only 1 person submitted OASIS; the agency had a team of corporate people that did it. During an interview on 03/25/25 at 3:05 p.m., Manager of Application Integration O said her team was responsible for submitting OASIS to IQIES. She said she managed the office informatics and application integration team, and they did OASIS transmissions. She said the team could not export OASIS unless it was locked. Manager of Application Integration O said OASIS were locked by the branch directors in the office. She said her team reviewed branches for locked status and would create a file that was submitted to the electronic medical record. She said this was done daily but were doing it 3 times a week (Monday, Wednesday, Friday) prior to August of 2024. She said the timeframe to submit OASIS in IQIES was 30 days. Manager of Application Integration O said her team pulled OASIS in locked status every day. She said she did not know the agency was late on 400 transmissions in the past 12 months because her team did not handle that; they only did the transmission portion and transmitted them to IQIES. She said reports and tracking were left up to regional leadership and regulatory teams and her team only did exporting and transmitting. She said late submissions from the agency would be from a number of things, mainly coding if the agency was waiting on something to lock the assessments, and there was an issue related to the coding. She said a lot of what was found was there was a delay in time from the visit synced and in the visit notes and getting the workflow locked and pushed through to where they could get the export file and create it with a lock status for all the assessments. She said the clinical managers and branch directors approved the orders and the OASIS coding team locked them. Manager of Application Integration O said it was a 2 to 3 team tier approach to getting it done. She said her team was only looking at the system and status of everything to pull OASIS and did it according to a schedule. During an interview on 03/26/25 at 9:06 a.m., VP of Quality OASIS and Coding J said she oversaw the internal OASIS coding team, completed OASIS education for the home health division, and did oversite for quality reporting. She said once her team put in coding the OASIS was sent back to the clinical manager for changes and to edit/lock the OASIS. She said then it went to Manager of Application Integration O’s team for OASIS transmitting. She said the goal was to get it to Manager of Application Integration O’s team within 7 days. She said depending on the referral information and the need to go back to the physician to confirm diagnosis was probably the thing that took the longest. She said reasons for late submissions was if a clinician went on PTO and the OASIS was not competed and locked, if there were payor changes the agency did not find out about until after the fact example 45 days later, these would cause OASIS to be late and the 30-day mark would be missed. VP of Quality OASIS and Coding J said she and her team monitored the 3330 error reporting code. She said she knew the agency was late on transmissions but did not know the exact number. She said 400 in the last 12 months did not surprise her. She said another reason for delayed submissions were face to face visits and if the face to face was not done before admission and the physician was doing it in the 30 days from admission then the agency was waiting to make sure they got a face to face that matched and validated against what the agency was seeing the patient for and what was listed as the primary diagnosis on the OASIS. She said it depended on how quickly the patient got in to the physician and how quick the agency got the visit note from the physician. She said those reasons were the cause of the bulk of the late submissions. VP of Quality OASIS and Coding J said the agency was aware of the 30-day submission timeframe. During an interview on 03/26/25 at 11:49 a.m., the RN Alternate Administrator said late OASIS submissions in IQIES could be from coding and if there was a hold on it. She said this could be from a lot of different things. She said it would not be coded if the OASIS was not accurate or if a face to face was not documented or completed. Record review of an OASIS Outcome and Information Set policy dated 09/26/24 indicated “…(a) Standard: Encoding and transmitting OASIS data. 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… 10. OASIS data will be accurate, completed, encoded and routinely transmitted to CMS in accordance with required submission timelines.…””

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: This is a continuing deficiency from survey event 38912-H1 exit 04/21/22. Based on interview and record review, the agency failed to ensure the POC contained the required elements to cover all safety measures to protect against injury, and patient specific interventions and education for 2 of 18 patient records reviewed for plans of care. (Patient #8 & #12) 1. Patient #8’s POC did not include patient teaching on weight monitoring and signs and symptoms to report for edema (swelling), or weight parameters that needed to be reported to the physician when out of range for Furosemide (water pill given to help treat fluid retention). 2. Patient #12’s POC did not include patient teaching on weight monitoring and signs and symptoms to report for edema (swelling), or weight parameters that needed to be reported to the physician when out of range for Furosemide, and did not include patient teaching on glucose (blood sugar) monitoring and signs and symptoms to report for low and high blood glucose levels, or glucose parameters that needed to be reported to the physician when out of range for Insulin (regulates blood sugar levels). This failure could result in Patient #8 and #12 not receiving proper care/instruction and could place patients at risk of not recognizing symptoms of fluid overload, high or low blood sugars, and could lead to complications and hospitalization. Findings included: Record review of Patient #8’s POC dated 02/11/25 to 04/11/25 indicated a SOC date of 02/11/25, and indicated he was 72 years old with diagnoses hypertensive heart disease with heart failure (heart can’t pump blood well enough to meet your body’s needs), atrial fibrillation (irregular heartbeat), cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), anxiety disorder (excessive and persistent worry, fear, and nervousness), long term use of anticoagulants (blood thinners), and history of falling. The POC indicated Patient #8 was ordered skilled nursing visits 1 time a week for 1 week, then 1 time a week every 2 weeks for 6 weeks, then 1 time a week for 2 weeks. The POC indicated heart failure monitoring RN/LVN to monitor patient for signs and symptoms of heart failure exacerbation, monitor for adherence with medication and heart failure management regimen. The POC medication list indicated Patient #8 was ordered Furosemide 40mg tablet, 1 tablet by mouth, 2 times daily. The POC did not include patient teaching on weight monitoring and signs and symptoms to report for edema (swelling), or weight parameters that needed to be reported to the physician when out of range. Record review of Patient #12’s POC dated 02/06/25 to 04/11/25 indicated a SOC date of 10/09/24, and indicated she was 87 years old with diagnoses including hypertensive heart disease with heart failure (heart can’t pump blood well enough to meet your body’s needs) diabetes mellitus (body either doesn’t produce enough insulin, or it resists insulin), chronic kidney disease stage 4 (severe loss of kidney function), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), anxiety disorder (excessive and persistent worry, fear, and nervousness), long term use of anticoagulants (blood thinners), and long term use of insulin (regulating blood sugar levels). The POC indicated Patient #12 was ordered skilled nursing visits 1 time a week for 8 weeks and physical therapy 1 time a week for 8 weeks. The POC medication list indicated Patient #12 was ordered Furosemide 20mg tablet, 1 tablet by mouth, 2 times daily. The medication list also included Insulin Glargine 100 unit/ml (3 ml) subcutaneous (under the skin) pen, sliding scale 4 times daily, and Lantus Solostar insulin 100 unit/ml (3 ml) subcutaneous pen 10 units daily. The POC did not include patient teaching on weight monitoring and signs and symptoms to report for edema (swelling), or weight parameters that needed to be reported to the physician when out of range. The POC also did not include patient teaching on glucose (blood sugar) monitoring and signs and symptoms to report for low and high blood glucose levels, or glucose parameters that needed to be reported to the physician when out of range. During an interview on 03/26/25 at 9:32 a.m., RN CM K said POCs were updated anytime with needs and at recertification every 60 days. She said the RN or therapist created the POC. She said a POC for insulin should include for the skilled nurse to teach on how to administer insulin, calculate sliding scale, teaching on site/where to give, blood sugar parameters and when to call the doctor. She said a patient on insulin should have blood sugar parameters. She said a POC for Furosemide should include to check weights, weight parameters, and if a weight gain of 5 or more pounds in a week call the doctor. She said by not having these items on the POC it could affect the patient tremendously. She said blood sugar parameters were needed to take care of the patient. During an interview on 03/26/25 at 9:41 a.m., RN CM K said she began auditing POCs the last 2 weeks. She said before that someone was doing chart audits remotely. RN CM K said she looked at the POCs after it was completed by the clinician. She said clinicians went through training upon hire online and it broke down OASIS in sections. She said the POC was built from the OASIS and the clinicians were in training 9 to 10 weeks, and longer if needed. During an interview on 03/26/25 at 9:56 a.m., RN CM L said the RN or PT created the POC when they were out doing the SOC and it was based on the patients’ diagnoses and the main focus. She said the agency focused on what they were doing for the patient and would add that to the POC. She said the POC was updated as needed. She said the agency had a heart failure diversion program and it would be on the POC if a patient had heart failure and if it was the main focus. She said the heart failure diversion program had specifics such as weight gain and what to do in the event of weight gain. RN CM L said the specific teachings including weight monitoring would be on the POC. She said blood sugar parameters on a POC for a patient on insulin. She said there was no reason for a patient not to have parameters and teachings on the POC. She said the agency always had parameters and teaching. During an interview on 03/26/25 at 10:04 a.m., RN CM L said once the clinician created the POC it went to her and she looked over it, then it went to coding and coding made sure everything was on there that needed to be. She said every POC was reviewed. RN CM L said every clinician was trained upon hire on how to create a POC. She said clinicians were in training at least 9 weeks. During an interview on 03/26/25 at 10:10 a.m., RN M said clinicians completed training on POCs and what needed to be on the POC. She said there was computer training then field training. RN M said the RNs and PTs created the POC and they were updated every 60 days or with changes. She said a POC for a patient on insulin should include sharp safety, blood sugar parameters, and when to notify the physician, diabetic education, and teaching on insulin. RN M said a POC for a patient on Lasix should include weight monitoring for a patient with congestive heart failure, and when to take the medication if the medication was as needed. RN M said if a patient was on Lasix for congestive heart failure the POC should include when to notify the doctor and weight parameters. She said if blood sugar parameters were not on the POC and if the blood sugar was too high and the doctor was not notified the patient could go into diabetic ketoacidosis (serious, potentially life-threatening complication of diabetes that occurs when the body doesn’t have enough insulin) and could cause re-hospitalization. During an interview on 03/26/25 at 10:18 a.m., RN N said she had been with the agency since December 2024. She said training included online for 4 days and training with a preceptor which included care plans. RN N said a POC for a patient on insulin should include who did the injections, blood sugar parameters, and teaching on high/low blood sugars. She said a patient on Lasix the POC should include fluid restrictions and teaching. She said for heart failure there should be daily weight monitoring, fluid restrictions, low salt diet, monitoring for signs of fluid overload, monitoring weight parameters, and when to call the nurse or doctor should be on the POC. RN N said the POCs were reviewed by the clinical managers. During a concurrent interview on 03/26/25 at 11:55 a.m., the RN Supervising Nurse said a POC for a patient on insulin should include safety measures, diabetic precautions, parameters for blood sugars, and signs/symptoms for high and low blood sugars. The RN Supervising Nurse said a POC for a patient on Lasix should include weight parameters, to weigh patient, congestive heart failure and fluid retention education, and instruct on daily weights. She said if these were not on the POC if could lead to fluid overload and increased edema. The RN Alternate Administrator said blood sugar parameters on the POC ensured the clinicians obtain the blood sugars and they might forget to check the blood sugar if the POC did not have parameters. During an interview on 03/26/25 at 12:05 p.m., the RN Alternate Administrator said POCs were reviewed until they were completed. She said the agency also reviewed charts in PI audits including visit notes, orders, and to make sure the clinicians were following the POC. She said 10 charts were audited per quarter. During an interview on 03/26/25 at 12:19 p.m., the RN Alternate Administrator reviewed Patient #12’s POC and said it did not include blood sugar parameters and there were no weight parameters. She said there was no specific teaching except medication management which included all medications but were not specific. She said the POC included diabetic precautions but there was no specific teaching. Record review of a Physician Orders and Medical Supervision of the Plan of Care policy dated 11/04/24 indicated “…2. Each patient receives the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed… The current 485/Plan of Care will include… d. Types of services, supplies and equipment required… l. Safety measures to protect against injury… o. Patient specific interventions and education; measurable outcomes and goals identified by the agency and the patient… q. Other items that may be patient or diagnosis specific…” Review of Furosemide (Lasix) instructions undated and accessed at https://nursing.unboundmedicine.com/nursingcentral/view/Davis-Drug-guide/51345/all/furosemide#:~:text=Monitor%20daily%20weight%2C%20intake%20and,pulse%20before%20and%20during%20administration on 03/27/25 indicated “…Assess fluid status. Monitor daily weight, intake and output, amount and location of edema (swelling), lung sounds, skin turgor(elasticity), and mucous membranes (inner lining of some organs and body cavities). Notify health care professional if thirst, dry mouth, lethargy (extreme tiredness), weakness, hypotension (low blood pressure), or oliguria (low urine output) occurs… Advise patient to contact health care professional if weight gain greater than 3lbs in 1 day...” Review of About Insulin Resistance and Type 2 Diabetes dated 05/15/24 and accessed at https://www.cdc.gov/diabetes/about/insulin-resistance-type-2-diabetes.html on 03/27/25 indicated “...Insulin is a key hormone that regulates your blood sugar levels… Sometimes this finely tuned system can get out of balance. When your body is exposed to too much blood sugar over an extended period of time, you can develop insulin resistance…” Review of Monitoring Your Blood Sugar dated 05/15/24 and accessed at https://www.cdc.gov/diabetes/diabetes-testing/monitoring-blood-sugar.html?CDC_AAref_Val=https://www.cdc.gov/diabetes/managing/managing-blood-sugar/bloodglucosemonitoring.html on 03/27/25 indicated “…Monitoring your blood sugar is the most important thing you can do to manage diabetes… Many factors like food choices, medicines, and physical activity cause your blood sugar to change throughout the day. Some change is normal, but when your blood sugar is too high or too low, this can cause problems. Monitoring will help you figure out what affects your numbers, find patterns, and adjust as you go. By checking regularly you’ll be more likely to achieve your blood sugar target ranges. Monitoring also helps your health care team make decisions about your diabetes care plan. Your doctor will tell you when and how often to check your blood sugar levels…””

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure all patient care orders were recorded in the plan of care for 1 of 18 patients records reviewed. (Patient #8) Patient #8’s POC did not include referral orders that included monthly weights and specific blood pressure parameters. This failure could result in abnormal findings not reported to the physician and could place patients at risk of receiving inadequate care and services. Findings included: Record review of an Order Form for Patient #8 dated 02/11/25 from NP P indicated home health referral. Further review of the instructions indicated weigh patient on a monthly basis and record in patient’s vitals chart. Blood pressure must be measured using an appropriate size manual arm blood pressure cuff. Hold blood pressure medications if systolic blood pressure (top number) is greater than 100 or diastolic blood pressure (bottom number) is less than 60, report abnormal as needed. Record review of Patient #8’s POC dated 02/11/25 to 04/11/25 indicated a SOC date of 02/11/25, and indicated he was 72 years old with diagnoses hypertensive heart disease with heart failure (heart can’t pump blood well enough to meet your body’s needs), atrial fibrillation (irregular heartbeat), cardiomyopathy (disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), anxiety disorder (excessive and persistent worry, fear, and nervousness), long term use of anticoagulants (blood thinners), and history of falling. The POC indicated Patient #8 was ordered skilled nursing visits 1 time a week for 1 week, then 1 time a week every 2 weeks for 6 weeks, then 1 time a week for 2 weeks. The POC indicated licensed professional to report vital signs falling outside the following established parameters which included systolic bp less than 90 or greater than 180 and diastolic bp less than 50 or greater than 100. The POC did not include the orders from the referral order form. Record review of Patient #8’s electronic record did not include any communication notes or orders that indicated the physician changed the orders of monthly weights and specific blood pressure parameters from the referral order. During an interview on 03/26/25 at 9:32 a.m., RN CM K said POCs were updated anytime with needs and at recertification every 60 days. She said the RN or therapist created the POC. She said orders from a referral went on the POC. She said if a referral order said to weigh monthly, the clinician would call the doctor and clarify and document in a coordination note and on the POC. She said if the referral order had a specific set of bp parameters, the clinician would call the doctor and clarify and put those parameters on the POC. During an interview on 03/26/25 at 9:41 a.m., RN CM K said she began auditing POCs the last 2 weeks. She said before that someone was doing chart audits remotely. RN CM K said she looked at the POCs after it was completed by the clinician. She said clinicians went through training upon hire online and it broke down OASIS in sections. She said the POC was built from the OASIS and the clinicians were in training 9 to 10 weeks, and longer if needed. During an interview on 03/26/25 at 9:56 a.m., RN CM L said the RN or PT created the POC when they were out doing the SOC and it was based on the patients’ diagnoses and the main focus. She said the POC was updated as needed. She said referral orders went on the POC. She said if the order had monthly weights and specific bp parameters, they would go on the POC. She said when doing the OASIS, the clinician would add it at that time. She said if orders were not on the POC it could affect the patient adversely (negatively) and the agency wanted to make sure they were following those orders. During an interview on 03/26/25 at 10:10 a.m., RN M said clinicians completed training on POCs and what needed to be on the POC. She said there was computer training then field training. RN M said the RNs and PTs created the POC and they were updated every 60 days or with changes. She said there was a protocol for vital sign parameters and were only changed with specific orders. She said an order for monitor weight monthly should be on the POC. She said if the orders were not on the POC it could affect the patient by how they took their medications. During an interview on 03/26/25 at 10:18 a.m., RN N said she had been with the agency since December 2024. She said training included online for 4 days and training with a preceptor which included care plans. She said orders from a referral were put on the POC. She said the skilled nurse looked at the referrals/orders. RN N said she remembered Patient #8 but could not remember the referral orders because it had been a while. During an interview on 03/26/25 at 12:05 p.m., the RN Alternate Administrator said POCs were reviewed until they were completed. She said the agency also reviewed charts in PI audits including visit notes, orders, and to make sure the clinicians were following the POC. She said 10 charts were audited per quarter. During an interview on 03/26/25 at 12:10 p.m., the RN Alternate Administrator the referral orders for Patient #8 were not on the POC. She said there was a verbal agreeance to the POC but there was nothing in the narrative that told why the physician changed the POC. She said on the POC where it showed “yes” to verbal order indicated the physician agreed with the POC. Record review of a RN Case Manager job description dated January 2024 indicated “…2. Performs patient comprehensive assessments and collaborates with patient multi-disciplinary care team (PT, OT, ST, MSW, and paraprofessionals) and other health care professionals to develop/modify and implement an individualized patient plan of care as per physician orders that ensures quality, proper discharge planning and achieves desired outcomes and goals…” Record review of a Physician Orders and Medical Supervision of the Plan of Care policy dated 11/04/24 indicated “…3. Orders are integrated from all physicians/allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient…””