Best Healthcare Services

“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 electronically transmit completed OASIS (a standardized data set that measures the quality and outcomes of home health patients) assessments to the CMS system for all Medicare patients within 30 days of completing the OASIS assessment of the beneficiary (patient) for 27.59% (32 of 116) of assessments transmitted during 08/24/2023-08/24/2024. This failure prevented the agency’s patient data from being made available to CMS within 30 days of the OASIS completion dates for analysis to identify agency performance levels in the provision of patient care. Findings included: During pre-survey activity on 08/24/2024: The surveyor reviewed the agency OASIS report titled, “HHA Error Summary by Agency” from IQIES (an internet-based system that includes survey and certification functions) during the one-year of 08/24/2023-08/24/2024. The HHA Error Summary by Agency report included 32 of 116 OASIS assessments (27.59%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment. An interview was conducted with the Adm/DON on 08/27/2024 at 2:00 PM. The Adm/DON stated she was responsible for submitting OASIS assessments to the CMS system. An interview was conducted with the Adm/DON on 08/30/2024 at 1:09 PM and the surveyor reviewed the error summary report which included 32 OASIS assessments submitted late. The Adm/DON stated during the period under review, she frequently traveled out of the country. When the Adm/DON logged in to the system outside the United States, it could not be accessed. The Adm/DON thought some OASIS assessments had been submitted, but later looked and noticed the assessments had not been submitted, did not know why they were not submitted, and was mad when she discovered it, which resulted in the agency not following its policy. Agency Policy titled, “Timelines IM.35” with a revision date of 05/02/2024, read in part, “…Purpose To establish timely parameters for all medical record information… Procedure… II. All completed and encoded OASIS data will be transmitted… to the CMS collection site within 30 days of the M0090 date…””

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review and interview, the agency failed to follow their agency policy to ensure notes were written on the day of service and incorporated into the patient record within 14 days in two of seven records reviewed (Patient 2 and 3) who received skilled nursing services. This failure placed the agency patients at risk of not receiving the appropriate care and services due to their current health status not being incorporated into the records. Findings included: Agency Policy titled, “Timelines IM.35” with a revision date of 05/02/2024, read in part, “…Procedure I. Agency staff, physician(s) and/or non-physician practitioner(s) and physician office staff, as appropriate, will be oriented to the following parameters… D. Daily progress notes with correlating time sheets are turned in within a maximum of seven calendar days… IV. All medical record information will be incorporated into the patient’s/patient’s medical record in a timely manner…” Agency Policy titled, “ Timelines – Addendum IM.35-TX” with a revision date of 04/14/2023, read in part, “…Procedure I. In addition to the requirements defined in the Timelines policy in the Management of Information section of the Administrative Policy Manual, the following requirements will also be met: A. All clinical and progress notes will be written the day service is rendered. B. All medical record information will be incorporated into the patient’s/client’s medical record within 14 working days…” Patient 2: Record review of the electronic health record included a plan of care dated 05/10/2024 to 07/08/2024 that was electronically signed by the Adm/DON. The plan of care included an order for a nurse to visit the client one time a week for nine weeks. The electronic record included a calendar of scheduled visits for LVN on 05/11/2024 and 05/17/2024. The visit note scheduled for 05/11/2024 was dated 05/09/2024 and did not include the visit start and end time, vital signs, and LVN’s electronic signature. The visit note dated 05/17/2024 did not include the visit start and end time and LVN’s electronic signature. During a phone interview with LVN on 08/30/2024 at 12:43 PM, the surveyor asked if the scheduled visit on 05/11/2024 was conducted on 05/09/2024 and why the visit notes dated 05/09/2024 and 05/17/2024 were incomplete. LVN stated the visit was conducted on 05/11/2024. The LVN stated during the interview, he opened the electronic health record and both visit notes were completed. During the interview, the surveyor again reviewed the visit notes in the electronic health record and both had been completed since the surveyor review on 08/29/2024. The surveyor asked when the visit notes were completed. LVN stated two days ago. [LVN] stated he had an accident in May and could not complete the notes at that time. Patient 3: Record review of the electronic health record included a plan of care dated 06/04/2024 to 08/02/2024 that was electronically signed by the Adm/DON. The plan of care included an order for a nurse to visit the patient three times a week for four weeks then one time a week for five weeks. The electronic record included a nurse visit note conducted by the Adm/DON on 07/03/2024 that was not electronically signed or dated. The record did not include nurse visit notes for the four weeks of 07/07-07/13/2024, 07/14-07/20/2024, 07/21-07/27/2024 and 07/28-08/02/2024. One nurse visit was ordered for each of the four weeks. During an interview with the Adm/DON on 08/28/2024 at 1:20 PM, the surveyor asked why the nurse visit note dated 07/03/2024 was not electronically signed and dated. The Adm/DON stated she did not know. During an interview with the Adm/DON on 08/28/2024 at 3:30 PM, the surveyor asked why weekly nurse visit notes were not completed starting the week of 07/07/2024. The Adm/DON stated the nurse visit notes would not upload in the electronic health record due to an error within the system. The Adm/DON stated she received an email from the electronic health record vendor on 08/27/2024 stating the problem was fixed and the Adm/DON was now working on completing the nurse visit notes. The Adm/DON stated she was responsible for ensuring clinical visit notes were completed on the day of service and ensuring the notes were placed into the patient records within 14 working days. The Adm/DON stated agency policies were not followed because of the issues they were having. During an interview with the Adm/DON on 08/30/2024 at 1:22 PM, the surveyor asked why the nurse visit notes were not documented on paper since there was a problem with the electronic health record. The Adm/DON stated she should have written the notes on paper.”