Urgent Care Home Health 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 assessment to the CMS system, within 30 days of completing the assessment of the patient for 665 of 2464 assessments processed for the time reviewed of 06/01/2024 to 12/31/2024. 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. The findings include: The HHA Error Summary Report, retrieved from the iQIES website for the time of 06/01/2024 to 12/31/2024 was reviewed. Review of the HHA Error Summary Report for the time-period 06/01/2024 to 12/31/2024 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 665 assessments and the percentage of assessments with this error was 26.99% of the total of 2464 assessments completed by the Agency. An interview was conducted with the Alternate Administrator on 2/26/2025 at 3:30 p.m. The HHA Error Summary Report was reviewed with the Alternate Administrator. The Alternate Administrator stated the Agency was not aware of the late submissions of OASIS assessments, however she stated that this failure was due to the Agency transmitting the OASIS to a Quality Assurance consultant group to ensure the Agency’s compliance with submissions. During a record review of an Agency policy titled, “IM. 9 Timeliness,” dated 7/12/2021, read in part, “…All agency staff…, will be oriented to the following parameters...6. The complete comprehensive assessment with incorporation of the current version of OASIS items is completed no later than five calendar days after the start of care date for all patients…with OASIS submission/export to CMS within 30 days of 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 enforce written policies addressing infection control including the prevention of the spread of infectious and communicable disease due to no cleaning of medical equipment was performed during patient care by 1 of 1 employees (LVN B) observed. This failure placed the agency’s clients at risk for an infection. Findings include: During an observation on 2/25/2025 at 1:30 pm at Patient #5’s home, the surveyor was observing the vital signs and blood sugar testing of Patient #5 with LVN B. Further observation revealed that prior to testing the blood sugar of Patient #5, LVN B obtained the blood sugar monitor from the medical bag, took Patient #5’s blood sugar, then placed the blood sugar monitor in the medical bag without cleaning the blood sugar monitor. During an interview on 2/25/2025 at 2:00 p.m. with LVN B, LVN B was informed of the observation findings. When asked the reason of the lack of cleaning the blood sugar equipment during patient care, LVN B responded, “Her blood didn’t touch the monitor.” During an interview on 2/27/2025 at 10:00 a.m. with the Alternate Administrator, the Administrator was informed of the above findings. When asked why the failure occurred, the Alternate Administrator stated that LVN B was aware of the cleaning policies of the agency and needs to be reeducated on infection control. Record review of an agency policy titled, “Cleaning and Management of Supplies and Equipment,” dated 3/05/2010, read in part, “Agency Staff providing patient care will follow Agency procedure for cleaning and management of supplies and equipment according to …state and federal laws…Staff will be responsible for cleaning on a regular basis…procedures for cleaning and Management of Supplies and Equipment...Blood Glucose monitoring Equipment…Frequency…Between patient use…wipe and allow to air dry.””