First Response Home Health Services LLC

“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 transmit completed OASIS assessments to the CMS system within 30 days of completing the OASIS assessment of the beneficiary (patient) for 71.43% of the assessments (30 of 42) transmitted during the period of 10/1/23 to 9/24/24. This failure prevented the agency’s patient data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. Findings include: On 10/18/24 at approximately 9:50 am, the surveyor reviewed the agency OASIS HHA Error Summary by Agency report from 10/1/23 through 9/24/24. The error summary report read in part…”Error -3330, record submitted late: The submission date is more than 30 days after M0090. # (number) of assessments processed, 42.”… 30, 71.43% submitted over 30 days after the M0090 date. An interview was conducted on 10/18/24 at 10:05 am. The surveyor asked the Office Manager who was responsible for submitting the OASIS. The Office Manager explained that she herself was responsible. The surveyor asked the Office Manager what her process was for submitting the OASIS. The Office Manager explained that she submitted once a month. The surveyor reviewed the last fiscal year from 10/1/23 through 9/30/24 HHA Error Summary by Agency report indicating that 30 of 42 submitted, 71.43% were submitted late, over 30 days after the M0090 date. The Office Manager said, “It’s my fault, I didn’t submit like I should have.” An interview was conducted on 10/18/24 at 10:30 am with the Administrator/Supervising Nurse. The surveyor reviewed the HHA Error Summary by Agency with Administrator/Supervising Nurse. Surveyor asked the Administrator/Supervising Nurse who was responsible for submitting the OASIS. The Administrator/Supervising Nurse said, “the Office Manager.” Surveyor asked were the OASIS assessment completed timely. The Administrator/Supervising Nurse said, “Sometimes I am late completing them and sometimes the Office Manager is late submitting them.” Surveyor asked the Administrator/Supervising Nurse how the OASIS assessment being submitted late could affect the patients. The Administrator/Supervising Nurse said, “It could affect their care.” Agency policy, “Timelines IM.35” last reviewed 5/2/24 read in part…”Policy The agency will ensure timely provision of care and services to meet the patient’s/client’s needs in compliance with all federal and state laws and regulations…Procedure…II. All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set and the CMS-assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with the Federal Information Processing Standard (FIPS 140-2, issued May 25, 2001) from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date.”…”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on record review and interview, the nursing services failed to be provided under the supervision of a registered nurse, according to agency policy in 5 (#1, #2, #3, #6 and #7) of 7 active records reviewed where the agency’s licensed vocational nurses were conducting skilled nursing visits. This failure placed patients’ #1, #2, #3, #6 and #7 at risk for inadequate care and potential harm. Findings include: Patient #1: The record contained a plan of care for episode 6/18/24 to 8/16/24 with a start of care date of 4/19/24. The plan of care included orders for skilled nursing visits 1 time a week for 9 weeks. Patient #1’s record contained 8 skilled nurse visits conducted and signed by LVN A during the episode of 6/18/24 to 8/16/24. There was no evidence of a LVN supervisory visit from 6/18/24 to 8/16/24 (61 days). Patient #2: The record contained a plan of care for episode 6/28/24 to 8/26/24 with a start of care date of 4/29/24. The plan of care included orders for skilled nursing visits 1 time a week for 9 weeks. Patient #2’s record contained 5 skilled nurse visits conducted and signed by LVN A during the episode of 6/28/24 to 8/26/24. There was no evidence of a LVN supervisory visit from 6/28/24 to 8/26/24 (61 days). Patient #3: The record contained a plan of care for episode 6/18/24 to 8/16/24 with a start of care date of 12/31/21. The plan of care included orders for skilled nursing visits 1 time a week for 9 weeks. Patient #3’s record contained 8 skilled nurse visits conducted and signed by LVN A during the episode of 6/18/24 to 8/16/24. There was no evidence of a LVN supervisory visit from 6/18/24 to 8/16/24 (61 days). Patient #6: The record contained a plan of care for episode 6/25/24 to 8/23/24 with a start of care date of 4/26/24. The plan of care included orders for skilled nursing visits 1 time a week for 9 weeks. Patient #6’s record contained 8 skilled nurse visits conducted and signed by LVN A during the episode of 6/25/24 to 8/23/24. There was no evidence of a LVN supervisory visit from 6/25/24 to 8/23/24 (61 days). Patient #7: The record contained a plan of care for episode 6/30/24 to 8/28/24 with a start of care date of 6/30/24. The plan of care included orders for skilled nursing visits 1 time a week for 9 weeks. Patient #7’s record contained 8 skilled nurse visits conducted and signed by LVN A during the episode of 6/30/24 to 8/28/24. There was no evidence of a LVN supervisory visit from 6/30/24 to 8/28/24 (61 days).. An interview was conducted on 10/17/24 at 10:45 am with the Administrator/Supervising Nurse. The surveyor reviewed the active patient charts audit findings for patients’ #1, #2, #3, #6 and #7 in that no LVN supervision was found for any of the active patients with the Administrator/Supervising Nurse. The surveyor reviewed the agency policy that stated a registered nurse (RN) would perform LVN supervisory visits every 60 days. The Administrator/Supervising Nurse said, “I just completely missed doing them. (the LVN supervisory visits).” The surveyor asked how not performing the LVN supervisory visits could affect the patients. The Administrator/Supervising Nurse said, “The patient may not be getting the correct care.” Agency policy: Employee Supervision HR.60 Last Reviewed: 050224 read in part…”Purpose To establish employee supervision practices in accordance with applicable federal and state laws and regulations. Policy… II. Supervision will be performed within the time frame defined by policy…”.…D. Nursing Services 1. Nursing services are provided under the supervision of a RN. 2. A qualified RN will supervise the licensed professional/vocational nurse (LVN /LPN) at least every 60 days or more frequently if indicated by state practice act or based upon patient/client acuity.”