Community Home Health Care

The Home Health Agency (HHA) failed to encode and electronically transmit each completed OASIS (Outcome and Assessment Information Set) assessment to the CMS system within 30 days of the assessing clinician completing the assessment of the beneficiary, in order to allow an outside contractor to…

The Home Health Agency (HHA) failed to develop and implement a policy and procedure to include quality assurance measures for monitoring of the NEW process for the use of off-site contractors to review clinician’s Outcome and Assessment Information Set (OASIS) data items.

The agency failed to ensure that the Outcome and Assessment Information Set (OASIS) assessment was transmitted to the CMS system within 30 days of the M0090 (date assessment completed) in order to allow an outside contractor to complete a review of the OASIS data for 3 of 5 sampled…

The agency failed to ensure the OASIS data submitted to CMS accurately reflected the patient’s health status at the time of OASIS collection by the assessing clinician.

The Home Health Agency failed to ensure that the patients were informed in advance of the disciplines that would provide care and the frequency of the visits proposed for 17 out of 17 sampled patients, (Patients #1-#17). . The findings include: A record review was conducted for Sampled Patient (SP)…

The agency failed to ensure that the comprehensive assessment, including OASIS items, were completed within 5 calendar days of the start of care for 5 of 5 Medicare/Medicare Advantage patient’s reviewed, #3, #7, #9, #10, and #12. The findings include: Review of the clinical record for Patient #9…

The agency failed to ensure the Plan of Care was followed for 2 of 17 sampled patients, #3 and #4. The findings include: A review was conducted of the Plan of Care for Patient #3; Certification period of 08/16/2023-10/14/2023. The plan of care orders stated Skilled nurse was to obtain ankle…

The Home Health Agency's Administrator failed to be responsible for the day-to day operation of the Home Health Agency by failing to maintain an effective and ongoing Quality Assessment Performance Improvement (QAPI) program to ensure the quality and accuracy of comprehensive assessments, including…

The Agency failed to ensure that the updated CEMP for 2018 was received, reviewed, and approved by the Department of Health and Division of Emergency Management per state guidelines.

The Agency failed to provide initial training for 2 of 4 new employees (#F & #G), and failed to provide annual training for the bulk of existing employees in Emergency Preparedness Policies and Procedures.

The agency failed to ensure Discharge instructions were provided at the time of discharge for 5 of 5 discharged patients.

The Agency failed to issue Advanced Beneficiary Notice of Non-Coverage prior to day of discharge for 1 of 5 sampled discharged patients.

The Agency failed to review the Medication Profile for 3 of 13 sampled patients, #1, #2, and #7. The findings include: 1. On 9/10/2018 at 2:00pm, a home visit was conducted with a Physical Therapist (Employee E) for Patient #1 who lives in an Assisted Living Facility (ALF).

The Agency failed to follow the Plan of Care (POC) for Aide visits for 1 of 13 sampled patients, Patient #6. The findings include: Patient #6 had a Start of Care date of 8/18/2018 with diagnoses of acute bronchitis, kidney disease, history of falls, legal blindness, anemia and reflux.

The agency failed to ensure Home Health Aides report changes of condition to the Registered Nurse in charge of the patient for 1 of 1 sampled patients receiving Home Health Aide services.

The Agency failed to provide supervisory Home Health Aide (HHA) visits at least every 14 days for 1 of 13 sampled patients, Patient # 8. The findings include: Patient # 8 had a Start of Care on 4/14/2018 with diagnoses of Dementia with Behavioral Disturbances, and falls.