Mission Minded Home Healthcare

“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: determined by the Secretary), within 30 days of completing the assessment of the beneficiary. Based on record review and interview, the Agency failed to encode and electronically transmit each completed OASIS assessment (A tool used by CMS to collect certain patient information)to the CMS system, within 30 days of completing the assessment of the patient for 1 of 1 (100%) assessments processed for the time reviewed of 1/1/2025 to 12/31/2025. This failure resulted in the delay of data to be reported to CMS, which can affect patient care. Findings included: The HHA Error Summary Report, retrieved from the iQIES website for the time of 1/1/2025 to 12/31/2025 was reviewed and 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 1 assessment, and the percentage of assessments with this error was 100% of the total of 1 assessment completed by the Agency. An interview was conducted with the Administrator on 8/5/2026 at 1:30 PM. The HHA Error Summary Report was reviewed with the Administrator. The Administrator stated that the company was obtained in October 2025 and prior ownership was responsible for keeping track of OASIS submissions. Ultimately, the Administrator acknowledged the responsibility of the late submission. During a record review of an agency policy titled, “Reporting of Oasis Information,” last reviewed 10/31/2025, read in part… “The agency will encode and be capable of accurately transmitting OASIS data for each applicable patient within seven days of completing the OASIS data set using… software and according to current federal and/or state requirements…””

“Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient’s equipment when assisting with self-administered tests. This Standard is not met as evidenced by: Based on record review, observation, and interview, the agency failed to, when engaging in laboratory testing outside of the contact of assisting a patient in in self-administering a test with an appliance that had been cleared for that purpose of the Food and Drug administration, ensure the testing was in compliance with all applicable federal requirements in that: The agency did not have an active CLIA waiver in accordance with state law and federal law, as the waiver expired 5/5/26. This failure could result in agency’s staff not being legally authorized to conduct blood sugar monitoring. Findings include: Record review of the agency’s CLIA waiver reflected an expiration date of 5/5/2026. Further review revealed no evidence of renewal was conducted prior to 8/5/2026. During a home visit with Patient #5 on 8/6/2026 at 12:00 p.m., Patient #5 was observed receiving blood glucose testing from RN A while using Patient #5’s home glucose testing kit. During a record review of Patient #5’s clinical records, Patient #5’s start of care date to home care services was 7/8/2026, with a diagnosis of Diabetes Mellitus (uncontrolled blood sugar) and a certification period of 7/8/2026-9/5/2026. Further record review of Patient #5 clinical records revealed that Patient #5 was receiving skilled nursing services 6 times per week to assist in blood sugar monitoring. In a joint interview with the Administrator and Alternate Administrator on 8/5/2026 at 2:00 PM, Surveyor asked the Administrator if he was aware that the agency’s CLIA waiver had expired. The Administrator stated that he was aware and understood the importance of obtaining a CLIA waiver renewal. The Alternate Administrator verbalized that the nursing staff conducted blood sugar monitor testing during the home visits with the agency’s patients and understood the importance of adhering to the federal waiver guidelines. The Administrator verbalized responsibility in the delay of the renewal of the CLIA waiver, which was an oversight. Review of the agency policy and procedures titled “Laboratory Testing: Blood Glucose Monitors”, revised 10/31/2025, read in part… “The agency will obtain and maintain a current CLIA waiver for analysis of blood glucose levels via fingerstick…CLIA requirements apply to agency owned, staff owned or patient owned glucometers (when the nurse utilizes the patient’s glucometer)…”.”

“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 ensure the comprehensive assessment accurately reflected a review of all medications the patient was using at the time 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 enforce written policies addressing medication review during a home visit with 2 of 3 patients visited (Patient #5 and Patient #6) in that: 1) RN A failed to review and reconcile Patient #5 and Patient #6’s medication lists during the home visits. This failure placed the agency’s patients at risk of harm by consuming incorrect medications. Findings included: During a home observation for Patient #5, on 4/6/2026at 12:00 p.m., RN A was observed providing patient care. Further observation of RN A revealed that RN A failed to conduct a medication review Patient #5’s medication during the home visit to check for compliance.. During a home observation for Patient #6, on 4/6/2026at 10:00 a.m., RN A was observed providing patient care. Further observation of RN A revealed that RN A failed to conduct a medication review of Patient #6’s medication during the home visit to check for compliance. During a record review of Patient #5’s clinical records, Patient #5’s start of care date to home care services was 7/8/2026, with a diagnosis of Diabetes Mellitus (uncontrolled blood sugar) and a certification period of 7/8/2026-9/5/2026. Further record review of Patient #5 clinical records revealed that Patient #5 was receiving skilled nursing services 6 times per week to assist in blood sugar monitoring. During a record review of Patient #6’s clinical records, Patient #5’s start of care date to home care services was 6/14/2026 and a certification period of 6/14/2026-8/12/2026. Patient #6’s clinical records also revealed a diagnosis of dizziness and brain disease. Further record review of Patient #6 clinical records revealed that Patient #6 was receiving skilled nursing services once per week to assist mobility and gait teaching. During a review of RN A’s personnel record included education records, which revealed RN A’s date of hire was 6/5/2026, and RN was instructed on methods of conducting home visits on 6/5/2026. During an interview with RN A on 8/5/2026 at 3:00 p.m., RN A was asked about the above findings. RN A stated the agency instructed her on medication review and how to conduct home visits. During a joint interview with Administrator and Alternate Administrator on 8/7/26 at 1:00 p.m., the Alternate Administrator and Administrator were informed of the above findings. The Alternate Administrator accepted responsibility and stated that it is important for the nursing staff to conduct a medication review during all patients’ visits from the agency. The Administrator also stated that it was important for the agency’s nurses to conduct a medication review during home visits for safety reasons. During a review of the agency policy titled, “Medication Monitoring,” no date, read in part, “Agency staff will monitor each patient’s response to medications, including actual or potential medication related problems…ascertaining the patient’s perceptions regarding side effects and medication effectiveness…assessing non-compliance with medication orders…””