Adventist Home Health & Hospice

“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 assessment to the CMS system within 30 days of completing the assessment of the patient for 23 of 25 assessments processed for the time-period reviewed of 1/1/24 - 1/1/25. This failure resulted in data used to improve the effectiveness of home healthcare and improve patient care failing to be reported to CMS in the required time frame, which could affect patient care by failing to identify trends and agency shortcomings. Finding included: In a review of the HHA Error Summary Report for the time period of 01/01/2024 to 01/01/2025, the report identified Error #-3330. The description for Error #-3300 read in part, “Record Submitted Late: The submission date was more than 30 days after M0090 (item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified that the number of assessments with this error were 23 assessments and the percentage of assessments with this error were 92% of assessments completed by the Agency. In an interview with QA Personnel at 3:01 PM, she stated they review each assessment for completeness and accuracy based on the referral. She stated they usually required 48 hours for submission for the initial assessment, and they would follow up with the nurses if it went beyond that. She stated it went beyond that because “the nurses are busy and we have a hard time reaching them.” In an interview was completed with the Administrator and Alternate Administrator on 11/25/25 at 3:20 PM the surveyor showed Administrator the “Home Health Error Summary” report which indicated that 23 OASIS assessments were late by the agency. The Surveyor asked the Administrator and Alternate Administrator who was responsible for submitting assessments to OASIS. Alternate Administrator reported that she was. The Alternate Administrator stated that the assessments were being submitted late due to a delay in getting the Plan of Care’s completed and signed by physicians and the initial assessments completed by the nurses. The surveyor asked what the agency’s process was to ensure timely submissions of assessments. The Alternate Administrator stated that the QA team was responsible for following up with nurses to ensure the Plan of Care was submitted in a timely manner. She stated that “clearly that process is not working.” The Surveyor asked if late assessment submissions impacted on client care. The Alternate Administrator stated, “Of course it does. How could you tell if the patient is improving or not without the initial assessment documented? How would you coordinate client care?” Review of the Agency’s policy titled “Documentation Timeliness Policy (24-72 hours), undated, revealed that under the column “72-hour requirements” - “OASIS Assessments” was listed. Review of the Agency’s policy titled “Medical Record Information Timelines”, undated, revealed a document that read in part, “Completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic standards. It will be transmitted to CMS OASIS contractor within 30 days of the M0090 date.””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, record review, and interview, the agency failed to follow acceptable standards of practice to prevent the transmission of infections in 1 out of 3 patients (Patient 1) observed during a home visit in that RN A was observed not using hand hygiene or washing his hands when he removed the soiled wound dressing and before he applied the clean wound dressing and did not wash his hands or apply hand gel after he removed the soiled PICC line (Peripherally Inserted Central Catheter - a type of long term access for medications delivered into the veins) dressing and before he applied the clean PICC line dressing. Failure of the agency to ensure compliance with infection control practices puts the patients and employees at risk for acquiring a preventable infection and transmission/spreading of disease. Findings included: Record review of the agency policy titled, “Hand Hygiene,” revised 2/1/2017, revealed a document that read in part, “All Agency staff providing patient care will observe proper hand hygiene techniques…If hands are not visibly soiled, staff may use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described below. Alternatively, staff may wash hands with an antimicrobial soap and water in all clinical situations described below: 1. Decontaminate hands prior to initial entry into the supply bag, 2. Decontaminate hands before having direct contact with the patients/clients; 3. Decontaminate hands before and after performing any invasive procedures such as inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure, or before or after wound care; 4. Decontaminate hands after contact with a patient’s /client’s intact skin, even when gloves are worn; 5. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled; 6. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient/client; 7. Decontaminate hands after removing gloves; 8. Decontaminate hands before handling medication or food.” Further review of the policy revealed a statement which read, under the heading “Purpose”: “To ensure patient/client care staff practice proper hand hygiene techniques and nail care to aid in the prevention and spread of infection per CDC guidelines.” Review of the CDC’s site titled, “Clinical Safety: Hand Hygiene of Healthcare Workers,” dated 2/27/24 (https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html ) revealed a document that read in part, “Know when to clean your hands: Immediately before touching a patient. Before performing an aseptic task such as placing an indwelling device or handling invasive medical devices. Before moving from work on a soiled body site to a clean body site on the same patient. After touching a patient or patient’s surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal.” Further review of the document revealed the following: “Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient’s surroundings. Always clean your hands after removing gloves. Remember to remove gloves carefully to prevent hand contamination as dirty gloves can soil hands.” During an observation in Patient 2’s home at 9:00 AM on 11/24/25, RN A was observed using hand sanitizer before taking the client’s vital signs. He then donned (put on) gloves to begin the wound care, but did not wash hands or use hand sanitizer before donning the gloves. RN A used one pair of gloves to take off the soiled dressing, then put a new pair of gloves on to apply the new dressing but did not use hand sanitizer between changing gloves. RN A correctly washed his hands after the wound care, before donning a new set of gloves to remove the client’s soiled PICC dressing. After the old dressing was removed, RN A donned a pair of sterile gloves to put on the new PICC dressings but did not use hand sanitizer in between. In an interview with RN A at 9:55 AM, the Surveyor asked RN A what the agency’s policy was on hand hygiene between glove use. RN A stated it was to use hand sanitizer between glove changes and that he usually did that but he forgot today and added that it made his hands wet and difficult to put on the new pair of gloves. In an interview with the Administrator and Alternate Administrator at 3:20 PM on 11/25/25, the surveyor shared her observations of RN A and asked what the agency’s policy was on hand hygiene. The Alternate Administrator stated it was their policy to sanitize or wash hands when changing gloves and that was how they train their employees. The surveyor asked how not this doing could affect patient care, and the Administrator stated that it helped prevent the spread of infection.”

“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 observation, record review, and interview, the agency failed to maintain a current medication list for 3 of 3 patients for which home visits occurred (Patient 2, Patient 3, and Patient 4). This failure placed patients at risk of undetectable adverse events due to medications. Findings included: Record review of document titled “Medication Profile [Patient 2],” dated for the certification period of 11/8/25 - 1/6/26, revealed that the current list of medications for Patient 2 included the following: Gabapentin600 mg oral tablet, Escitalopram oxalate 5 mg oral tablet (treats seizures, relieves nerve pain), Methocarbamol (muscle relaxant) 750 mg oral tablet, Oxybutynin Chloride (treats bladder spasms) 0 mg 24hr extended release oral tablet, Oxycodone Hydrochloride (treats pain)10 mg oral tablet, Tizanidine (muscle relaxant) hcl 4 mg oral capsule, ondansetron (anti-nausea) HCl 4 mg Oral Tablet . Furthermore, the medication list did not include IV (intravenous - delivered through the veins) Meropenem (antibiotic - treats bacterial infection), despite the fact that the client was currently self-administering IV Meropenem through his PICC (Peripherally Inserted Central Catheter - a type of long term access for IV) medications). In an observation and interview in the home of Patient 2 on 11/24/25 at 9:00 AM, the surveyor requested to see Patient 2’s medications and compared them to the medication list obtained from the medication profile referenced above. The client stated he was currently self-administering IV Meropenem through his PICC. The Surveyor asked RN A why Meropenem was not on the medication list and he stated he was not sure, since this was his first time seeing Patient 2. The Surveyor asked Patient 2 how long he had been on Meropenem, and he stated “since he had been home from the hospital”. Record review of document titled “Medication Profile for [Patient 3],” dated for the certification period of 10/4/25 to 12/22/25, revealed that the current list of medications for Patient 3 included the following: Amitriptyline hcl (antidepressant) 100 mg oral tablet, Amlodipine Besylate 10 mg oral tablet (treats blood pressure), Baclofen (muscle relaxant) 20 mg oral tablet, Gabapentin 800 mg oral tablet, Ibuprofen (anti-inflammatory, pain relief) 200 mg oral tablet, Metoprolol Tartrate (slows heart rate and relaxed blood vessels) 100 mg oral tablet, Prazosin hcl (treats high blood pressure) 5 mg oral capsule, Tizanidine hcl (muscle relaxant) 4 mg oral tablet, Zolpidem Tartrate (sedative) 10 mg oral tablet, cranberry pills, buPROPion HCI (antidepressant) 200 MG 12HR Extended Release Oral Tablet, DULoxetine (treats depression) 30 MG Delayed Release Oral Capsule Further review revealed the medication list did not include Trazadone (treats depression). In an observation and interview in the home of Patient 3 and Patient 4 (who lived in the same residence) on 11/25/25 at 10:15 AM, the surveyor observed the Administrator refilling Patient 3’s pill box and was able to go over each medication with the nurse and patient as they were placed in the medication pill box. All medications on the list were accounted for, except for Trazadone. Patient 3 confirmed he was taking Trazadone every day before bed to help with sleeping and had been for several weeks. He was unsure of his exact start date. Record review of document titled “Medication Profile [Patient 4]” dated for the certification period of 11/8/25 - 1/6/26, revealed that the current list of medications for Patient 4 included the following: Amioadrone hcl (treats irregular heart rhythm)200mg oral tablet, Cetirizine hcl (anti allergy)10 mg oral tablet, Esomeprazole (treats heartburn) magnesium 20 mg delayed release oral capsule, Famotidine 40 mg oral tablet, Fluticasone Propionate (treats allergies) 50 mcg/actual metered dose nasal spray, Hydroxyzine pamoate (Hydroxyzine pamoate) 50 mg oral capsule, Meclizine hcl (treats nausea/dizziness) 25 mg oral tablet, Metoprolol Tartrate 25 mg oral tablet, Mirtazapine 45 mg oral tablet, Mupirocin 2% topical lotion (antibacterial ointment), Nystatin 100,000 unt/gm topical ointment (anti fungal ointment), Ondansetron hcl 8 mg oral tablet, Oxybutynin Chloride 15 mg 24hr extended release, oxygen 1-5L Nasal cannula, Vraylar (antipsychotic) 6 mg oral capsule, Zinc Oxide 5% topical cream, Medroxyprogesterone Acetate (synthetic hormone) 150 mg in 1 ml injection, Wellbutrin xl 300 (antidepressant) mg 24hr extended release oral tablet, Gabapentin 600 mg oral tablet, Melatonin 10 mg oral tablet, Probioitic, Wellbutrin xl 150 mg 24hr extended release oral tablet, Tramadol (treats pain) hcl 50 mg oral tablet, Losartan Potassium (treats high blood pressure) 50 mg oral tablet, cloNIDine HCI 0.2 MG Oral Tablet (multiple uses), zolpidem tartrate (sedative) 12.5 MG Extended Release Oral Tablet, cranberry concentrate, Vitamin D3 50mcg (2000 International Units) Softgel (vitamin), rosuvastatin calcium (helps cholesterol) 20 MG Oral Tablet, fluconazole (treats fungal infection)150 MG Oral Tablet, baclofen 5 MG Oral Tablet, lurasidone HCI 80 MG Oral Tablet Further review revealed the medication list did not include Wegovy, a medication given subcutaneously (injected into the skin) weekly for weigh loss. In an observation and interview at 10:50 AM on 11/25/24, the surveyor observed the Administrator (who was also an RN) refilling Patient 4’s pill box and was able to go over each medication with the nurse and patient as they were placed in the pill box. All medications on the list were accounted for, except for Wegovy. The Administrator stated either her or another nurse from the agency had been coming weekly to administer Wegovy to Patient 4 via subcutaneous injection (injected into the skin). She stated she would not administer it today, as it was not due until Saturday. In an interview with the Administrator at 3:15 PM on 11/25/25, the surveyor notified her the Patient 3 was missing Trazadone from his medication profile, and Patient 4 was missing Wegovy from her medication profile. The Administrator confirmed that these medications were not on the medication profile and that she would update them. The Surveyor asked how long Patient 4 had been on Wegovy, and she stated it had been several weeks. In an interview with the Administrator and Alternate Administrator on 11/25/25 at 3:20 PM, the Alternate Administrator confirmed that their policy was to have each client have an updated medication profile. She stated that at each visit the nurse should be reconciling the medications and updating it in the system, not just in their notebook. The surveyor asked if not having an up-to-date medication profile for each client could affect client care? The Administrated stated, “Oh yeah. We could miss medications which would affect patient management”. The surveyor asked if not having all medication on the patient’s medication list could put the client at risk for having reactions or side effects from the medication that could go unnoticed, and they agreed that this could be a risk. Review of policy titled “Medication List and Monitoring,” undated, revealed that “the agency will maintain a current, accurate list of all prescription and over-the-counter (OTC) medications taken by the patient/client. […] The Registered nurse will compare/reconcile the medication information (list) of what the patient is currently taking with the medications ordered to identify and resolve discrepancies…””