Hope Land Home Health Care 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 encode and electronically transmit each completed OASIS (a tool used by CMS to collect certain patient information) assessment to the CMS system, within 30 days of completing the assessment of the patient for 12 of 58 (20.69%) assessments processed for the time reviewed of 1/1/2025 to 12/31/2025 . This failure resulted in quality data used to continuously improve the effectiveness of home healthcare, failing to be reported to CMS in the required time frame which could result in patient harm. Findings include: The HHA Error Summary Report, retrieved from the iQIES (a web-based system used by CMS and healthcare providers to manage, survey, certification, and quality reporting data for post-acute and long-term settings) website for the time of 1/1/2025 to 12/31/2025 was reviewed. Review of the HHA Error Summary Report in IQIES for the time-period 1/1/2025 to 12/31/2025 identified Error #-3330. The description for Error #-3330 read in part, “Record Submitted Late: The submission date is more than 30 days after M0090 (Item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with the error was 12 assessments and the percentage of assessments with this error was 20.69% of the total of 58 assessments completed by the Agency. An interview was conducted with the Admin on 7/13//2026 at 11:30 AM. The HHA Error Summary Report was reviewed with the Admin. The Admin stated that the DON was responsible for submitting the OASIS reports. Admin stated they just recently took over the agency and are still trying to figure everything out and it must have fallen through the cracks. During a record review of an agency policy titled, “Reporting Oasis Information”, undated, read in part, “… the agency shall encode and electronically transmit each completed OASIS assessment to the State agency or the CMS OASIS contractor…within 30 days of completing the assessment…”.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on interview and record review, the agency failed to document all interventions including treatments and responses to those interventions in the patients’ medical record in 1 (Pt 3) of 7 patient records reviewed. This failure resulted in incomplete and untimely clinical documentation, preventing the agency from demonstrating that services provided were accurately and promptly documented in the patient record which could result in patient harm. Findings include: Record review of Pt #3’s plan of care, nursing notes, and visit schedule, revealed a start of care date of 3/19/2026 and an initial certification period of 3/19/2026-5/17/2026. Pt 3 had a diagnosis of infection following surgery and was ordered to receive skilled nursing visits 2 times per week for 1 week and 3 times per week for 8 weeks. Additional skilled nursing orders included: performing vital (temperature, heart rate, blood pressure, pain), clean wound, report any worsening to the physician. Review of visit documentation for dates 6/23/26, 6/25/26, 7/04/26, 7/07/26, 7/9/26, 7/11/26, 7/14/26 revealed no documentation by LVN A of vital signs, pain assessment, wound assessment. There was no documented evidence of skilled nursing services being provided except for a nursing signature. Record review of LVN A employment file revealed that she was contracted through a third-party agency to see Pt 3 for a first encounter on 6/15/26. During an interview with agency Alt DON and Alt admin on 7/15/26 at 11:45 AM, Surveyor asked why nursing notes for Pt 3 were incomplete for the dates of 6/23, 7/04, 7/07, 7/09, 7/11, and 7/14 conducted by LVN A. Alt DON stated that LVN A had a family member in the hospital and had been unable to complete her nursing notes. Surveyor asked if LVN A was able to complete the home visits for Pt 3 and if the agency confirmed that visits were being made. Alt DON stated that she confirmed the visits were being made and that the patient would call if LVN A was even 5 minutes late for her scheduled appointments. Surveyor asked Alt DON and Alt Admin why LVN A was able to conduct the visits but unable to complete any documentation regarding the visit. Alt Admin stated he attempted to contact LVN A to have her complete the notes, but she had not completed them as of 7/15/2026. Surveyor asked if Alt Admin or Alt DON attempted to contact the staffing agency where LVN A was contracted through and both denied any attempts to reach out to them. Review of agency policy titled “Standards of Conduct”, undated, read in part, “… all paperwork is to be completed accurately and in a timely manner.””