Wellspring Home Health Center, LLC

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on document review, record reviews, and interviews, the agency failed to accurately complete the Outcome and Assessment Information Set (OASIS) data for M0102 and M0104 for 6 of 7 patients (Patient #301, #302, #304, #305, #306 and #307). Failure to accurately complete the OASIS data places patients at risk for physical harm due to not receiving services in a timely manner. Findings included: 1. Record review of patient records for 6 patient records showed the following: a. Patient #301 was admitted on 12/04/25 with the primary diagnosis of pressure ulcer, sacral region, stage 4. The referral was completed on 12/03/25 for Skilled Nursing. The Start of Care OASIS showed a M102 date (Physician Ordered Start of Care) of 12/03/25 instead of the M104 (Referral date). The record showed no evidence of a physician ordered start of care date. b. Patient #302 was admitted on 09/17/26 with a primary diagnosis of essential hypertension, peritoneal abscess. The record showed a referral for Skilled Nursing, Physical Therapy, Occupational Therapy and Home Health Aides received on 09/10/26. The records showed documentation that Patient #302 was still hospitalized on 09/14/26 with an anticipated Start of Care date of 09/17/26. The Start of Care OASIS showed a M102 date (Physician Ordered Start of Care) of 09/16/26. There was no evidence of a physician ordered start of care date. c. Patient #304 was admitted on 02/20/26 with a primary diagnosis of heart failure unspecified. The record showed a referral for Skilled Nursing and Physical Therapy received on 02/18/26 with a physician ordered start of care date of 02/20/26. The Start of Care OASIS showed a M102 date (Physician Ordered Start of Care) of 02/18/26 instead of 02/20/26. d. Patient #305 was admitted on 06/25/26 with a primary diagnosis of acute respiratory failure with hypoxia, open wound to buttock. The record showed a referral for Skilled Nursing received on 06/16/26 with a physician ordered start of care date of 06/25/26. The Start of Care OASIS showed a M102 date of 06/23/26 instead of 06/25/26. e. Patient #306 was admitted on 12/09/25 with a primary diagnosis of non-pressure chronic ulcer to unspecified part of right lower leg. Record showed a referral for Skilled Nursing received on 11/17/25. The record showed evidence that the patient declined admission to home health services until 12/09/25. The Start of Care OASIS showed a M102 date (Physician Ordered Start of Care) of 12/08/26. The record showed no evidence of a physician ordered start of care date. f. Patient #307 was admitted on 05/21/26 with a primary diagnosis of fracture of unspecified part of neck of right femur. Record showed a referral for Physical Therapy received on 05/13/26 and completed on 05/20/26 when the agency was notified of Patient #307’s location. The Start of Care OASIS showed a M104 date (Referral date) of 05/13/26 instead of 05/20/26 when the referral was completed and approved. 2. On 09/30/26 at 1:00 PM, the Surveyor interviewed the agency’s Senior Advisor (Staff #301) about lack of accuracy in OASIS Data entry for M0102 and M0104. Staff #301 stated that the agency primarily serves Medicaid and Veterans Administration patients that do not require OASIS submission. Staff #301 acknowledged the inaccurate M102 and M104 entries and stated that admitting staff need additional education on the use of M102 and M104 on the OASIS.”

“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 document review, observation, and interview, the agency’s staff failed to follow infection prevention and control guidelines to use the proper hand hygiene technique and to clean contaminated equipment for 1 of 3 home visits (Patient #302). Failure of the agency to adhere to infection prevention and control guidelines places the patient at risk of harm due to exposure to infectious organisms. Findings included: 1. Document review of the agency’s undated policy and procedure titled, “Policy on Bag Technique,” showed that all field staff are expected to cleanse hands before entering/removing supplies from the bag. If additional supplies are needed during the visit, hands are to be cleaned before re-entering the bag. Alcohol based hand sanitizer gel may be used. All equipment is cleansed with disinfectant after use and before returning to the bag, such as scissors after removal of a dressing. 2. On 09/29/26 at 9:00 AM, the Surveyor observed a home visit for Patient #302. During the home visit, the Surveyor observed a Registered Nurse (Staff #303) perform vital signs and wound care to a peritoneal drain. The observation showed Staff #303 used the blood pressure cuff and pulse oximeter on the patient and failed to disinfect the instruments before returning them to the bag. Staff #303 removed gloves after removing the soiled drain bandage and failed to wash hands before applying new gloves to apply clean dressing. Staff #303 used scissors to remove the soiled dressing and failed to disinfect the scissors before cutting the clean dressing to be placed on the patient. Staff #303 failed to disinfect the scissors before returning them to the bag and instead placed them in a clean glove. 3. On 09/60/26 at 1:00 PM, the Surveyor interviewed the agency’s Senior Advisor (Staff #301) about the agency’s policies and procedures on disinfecting equipment, hand hygiene and bag technique. Staff #301 stated that the staff are trained to follow infection control procedures including proper disinfection of electronic devices and equipment after providing patient care. They also stated that agency provides staff with disinfecting wipes and sanitizers. Staff #301 stated that they recently provided a refresher training for staff regarding hand hygiene and bag technique. .”

“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 record review and interview, the agency failed to consult with the patient’s physician when the drug regimen review identified potentially severe adverse drug interactions for 2 of 7 patients (Patients #304 and #306). Failure to ensure the physician is aware of potential adverse events as identified from the drug regiment review places patients at risk of physical harm from unintended consequences of medication usage. Findings included: 1. Record review of the agency’s undated policy and procedure titled, “Clinical Policy - Medication Reconciliation and Notification to the Provider,” showed that the agency reconciles patient medication at the comprehensive assessment, at resumption of care, at recertification and when the medication list or patient’s condition changes. Clinically significant discrepancies, adverse effects, and nonadherence are reported to the authorizing practitioner. Notify the authorizing practitioner and any other prescriber who need to act, the same day for any of the following: a drug in the home that is not on the discharge or referral list, or a listed drug the patient is not taking; duplicate therapy, a likely significant interaction, or a dose that does not match the label and the order; an adverse effect, allergic reaction or suspected adverse drug event; nonadherence that affects safety or the plan goals; a change in condition that means the drug plan should be altered, including missing outcomes. CMS requires a prompt alert; the agency treats that alert as same day notice. 2. Record review for 2 of 7 patients showed the following: a. Patient #304 was admitted on 02/20/26 with a primary diagnosis of heart failure unspecified. The Start of Care OASIS showed that during the complete drug review the Skilled Nurse (Staff #303) identified clinically significant medication issues on M2001 and indicated that they contacted the provider by midnight of the next calendar day of the significant medication issue on M2003. The patient record showed no evidence that Staff #303 contacted the provider. b. Patient #306 was admitted on 05/21/26 with a primary diagnosis of fracture of unspecified part of the neck of right femur. The Start of Care OASIS showed that during the complete drug review the Skilled Nurse (Staff #303) identified clinically significant medication issues on M2001 and indicated that they contacted the provider by midnight of the next calendar day of the significant medication issue on M2003. The patient record showed no evidence that Staff #303 contacted the provider. 3. On 09/30/26 at 1:30 PM, the Surveyor interviewed the agency’s Senior Advisor (Staff# 301) about the agency’s process when a clinically significant drug issue is identified. Staff #301 stated that the agency notifies the provider of any clinically significant drug issue as described in agency policy. Staff #301 stated that for Patient #304 the Skilled Nurse (Staff #303) provided additional education to the patient regarding the use of opioid pain medications but did not notify the provider. Staff #301 also stated that the agency primarily provides services to Medicaid and Veterans Administration patients and acknowledges the need for additional OASIS training for the agency’s two Registered Nurses.”