Amazing Grace Systems Homehealth

“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 iQIES system, within 30 days of completing the assessment of the patient for 3 of 10 (Patient #4, Patient #5, and Patient #10) of the patient records reviewed. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare not to be reported to CMS in the required time frame. The findings included: The Error Summary Report, retrieved from the iQIES website for the time of 06/01/2024 to 12/31/2024 was reviewed. During review of the HHA Error Summary Report, no data was revealed of no OASIS assessments were completed. Further search revealed no data of a completed OASIS assessment for 1/1/2024 to 12/31/2024. During a record review of the agency’s census revealed 3 Medicare billed patients and 7 Medicare Advantage patients with 3 Medicare billed patients as: Patient #4 with a start of care date of 3/28/25, Patient #5 with a start of care date of 1/21/2024, and Patient #10 with a start of care date of 12/24/2024. Further record review revealed evidence of an OASIS assessment was completed and transmitted to IQIES at the start of care date. A joint interview was conducted with the Alternate Administrator and RN A on 5/13/2025 at 3:00 p.m., RN A stated that the agency was not billing for payment for the 3 Medicare patients due to the agency’s account in IQIES that were used for submission had expired. RN A also stated that the Administrator, who is responsible for the failure, did not use the IQIES account due to technological challenges. The agency currently billed the private Medicare Advantage insurance companies for patients, to which an OASIS was not required for payment. During a record review of the agency’s policy titled, “Initial Patient Comprehensive Assessment”, dated 5/4/2007, revealed, “Each patient will receive a patient specific comprehensive assessment with incorporates OASIS data set for Medicare…patients…the assessment will include…OASIS data…which would include pertinent diagnosis…medical history, etc.…” Further record review of the agency policies revealed no other OASIS policy was found.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that clients receiving skilled treatment under the direction of a practitioner had formal plans of care that contained all required elements for 5 of 7 active clients (Patients #2, #4, #5, #9, and #10) whose records were reviewed, in that: 1. Patients #2, #4, #5, #9, and #10’s Plan of Care and physician orders did not reflect frequency of home visits from any discipline. This failure placed the agency’s clients at risk for receiving inadequate service delivery. The findings included: During a record review of the clinical records on 5/14/2025 at 3:00 p.m., revealed the plan of care, labeled, “Home Health Certification and Plan of Care,” for Patients #2, #4, #5, #9, and #10. Further record review revealed as follows: Record review for the plan of care labeled, “Home Health Certification and Plan of Care,” for Patient #2 has a start of care date of 4/8/2025 with an admitting diagnosis of high blood pressure and depression. No frequency of visits was indicated in section 21 of the plan of care labeled, “Orders for Disciple and Treatments.” Record review for the plan of care labeled, “Home Health Certification and Plan of Care,” for Patient #4 has a start of care date of 3/28/2025 with an admitting diagnosis of diabetes (increased sugar in the blood). No frequency of visits was indicated in section 21 of the plan of care labeled, “Orders for Disciple and Treatments.” Record review for the plan of care labeled, “Home Health Certification and Plan of Care,” for Patient #5 has a start of care date of 1/28/2025 with an admitting diagnosis of diabetes (increased sugar in the blood). No frequency of visits was indicated in section 21 of the plan of care labeled, “Orders for Disciple and Treatments.” Record review for the plan of care labeled, “Home Health Certification and Plan of Care,” for Patient #9 has a start of care date of 4/14/2025 with an admitting diagnosis of diabetes (increased sugar in the blood). No frequency of visits was indicated in section 21 of the plan of care labeled, “Orders for Disciple and Treatments.” Record review for the plan of care labeled, “Home Health Certification and Plan of Care,” for Patient #10 has a start of care date of 11/12/2025 with an admitting diagnosis of arthritis (inflammation of the joints resulting in decreased mobility) and diabetes (increased sugar in the blood). No frequency of visits was indicated in section 21 of the plan of care labeled, “Orders for Disciple and Treatments.” During a joint interview with RN A, OM, the Alternate Administrator on 5/21/2025 at 12:00 p.m., RN A, OM, the Alternate Administrator were informed of the above findings. The Alternate Administrator acknowledged the discrepancy on the order and stated the frequency of the disciplines of nursing and physical therapy visits were not required by the Medicaid Advantage companies but understood the accuracy of the frequency of visits were important because the plan of care is a physician’s order. Review of the agency’s policy titled, “Plan of Care,” dated 12/29/2012, revealed in part, “C. The Plan of care, which includes the following elements, is developed in consultation with staff, patient, caregiver, physician and other providers involved in the patient’s care and will service as the initial plan of care: …11. Physician orders to include the discipline to render the services/treatments, the services or therapy modalities to be rendered and the frequency and during of the visits to be made…to specific procedures to be performed, including the amount, frequency and duration…” Review of the agency’s policy titled, “Implementing Care and Treatment,” dated 3/27/2010, revealed in part, “Agency staff providing patient care and treatment will be competent to the level of care...and the care provided will be within the frequency parameters established on the care planning document…””