Healing Hearts Home Health

“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 review of the iQIES Report “HHA Error Summary by Agency” report and the facility submission error report, and staff interview, the agency failed to ensure timely OASIS assessment submission for 21 patients (#8, #18, #19, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #unknown). The finding were: Review of the iQIES report “HHA Error Summary by Agency” report showed the agency had submitted 21 patient assessments which resulted in error code -3330, which indicated the assessment was submitted late. Review of the agency submitted error report showed 20 patients’ (#8, #18, #19, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #unknown) OASIS assessments were submitted late. The 21st patient name was not listed on the report. Interview with the administrator on 5/7/26 at 8:45 AM revealed the agency was aware of the 21 late submissions, and was working towards a 100% timely submission.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on medical record review, staff interview, and policy review, the facility failed to ensure clients received care in accordance with the plan of care for 5 of 35 patients (#14, #16, #17, #20, #32) reviewed. The findings were: 5. Review of the plan of care for the certification period 9/29/25 through 11/27/25 showed patient #14 was supposed to receive skilled nursing services one time per week. Review of the medical record showed no skilled nursing visits between 9/29/25 and 10/14/25. Review of the communication notes showed no notes regarding missed skilled nursing visits between those dates. Interview with the administrator on 5/7/26 at 12:56 PM confirmed no skilled nursing visits occurred between 9/29/25 and 10/14/25 and verified there were no notes regarding why the visits were missed. 6. Review of the facility’s policy “Patient Bill of Rights,” policy 2-002.1, revised July 2025 showed “...F. The organization shall ensure that the patient receives all services outlined in the plan of care.” Review of the plan of care for the certification period 10/27/25 through 4/30/26 showed patient #16 was supposed to receive skilled nursing one time per week. Review of the medical record showed no skilled nursing visits for the weeks of 2/1/26 or 2/8/26. Review of communication notes showed no notes regarding a missed nurse visit for those dates. Interview with the administrator on 5/7/26 at 1:46 PM revealed the calendar showed missed nursing visits for those two weeks, but there was no narrative note to show why the visits were missed. 2. Review of the plan of care for the certification period 10/27/25 through 3/25/26 showed patient #17 was supposed to receive home health aide services five times per week. Review of the medical record showed only four home health aide visits the week of 2/8/26. Review of communication notes showed no notes regarding a missed home health aide visit that week. Interview with the administrator on 5/7/26 at 1:46 PM revealed the calendar showed a missed visit on 2/11/26 but there was no narrative note to show why the visit was missed. 3. Review of the plan of care for the certification period 6/1/25 through 3/31/26 showed patient #20 was supposed to receive home health aide services five times per week. Review of the medical record showed only four home health aide visits the week of 2/15/26. Review of communication notes showed no notes regarding a missed home health aide visit that week. Interview with the administrator on 5/7/26 at 1:46 PM revealed the calendar showed a missed visit for 2/17/26 but there was no narrative note to show why the visit was missed. 4. Review of the plan of care for the certification period 11/1/25 through 8/31/26 showed patient #32 was supposed to receive skilled nursing every two weeks. Review of the medical record showed a skilled nurse visit on 12/4/25, a narrative note dated 12/26/25 which showed the patient did not answer the door, and then a note dated 1/22/26 which showed the patient was requesting discharge. Interview with the administrator on 5/7/26 at 1:46 PM revealed the calendar showed no answer at the door on 12/19/25 and 1/2/26. He stated the 1/15/26 visit was marked as “declined and not reassigned” which meant the staff declined the visit and it was not reassigned to another staff.”