Every finding on record at Aging Paradise Inc

An unannounced Complaint Survey, #2023002730, was conducted on 03/07/2023 at Aging Paradise Inc., Home Health Agency provider. The provider is not in compliance with 42 CFR (Code Of Federal Regulations) Part 484, Subpart A-C, Conditions of Participation for Home Health Agencies.

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 Home Health Agency (HHA) failed to ensure that the completed Outcome and Assessment Information Set (OASIS) Assessments were transmitted within thirty (30) days of the patient assessment completion for 3 of 3 sampled patient's records ( Patient #1, #2 and #3). The findings included: 1) Review of Patient #1’s Electronic Medical Record (EMR) documented a Recertification OASIS by a Skilled Nurse, submitted on 01/12/23. Further review of the patient’s EMR lacks evidence of Physician Plan of Care (POC) for the recertification period from 01/14/23 to 03/14/23. Review reveals the OASIS did not document that it was transmitted as required. Review of Patient #1’s EMR documented a Skilled Psychiatric Nurse visit was completed between 01/19/23 through 02/09/23. Further review of Patient #1’s EMR documented a physician's order, dated 02/02/23 for Physical Therapy (PT) Evaluation and Treatment. Review of Patient #1’s EMR documented a Physical Therapy Evaluation dated 02/06/23 and subsequently a Physical Therapist Assistant (PTA)'s visit from 02/06/23 through 02/28/23. Review of Patient #1's EMR documented a Physical Therapy Re-evaluation dated 03/01/23. On 03/07/23 at 2:45 PM, a side-by-side review of Patient #1’s EMR was conducted with the Administrator who confirmed that the patient’s OASIS assessment was completed on 01/12/23 was submitted but had not been exported/transmitted and that a Physician's POC wasn't generated; explained that once a patient had a completed OASIS assessment, it is coded, transmitted and generates a POC that it is sent to the physician; the Administrator explained that Patient #1's Recertification was done on 01/12/23 and because it had not been transmitted, a Physician's POC was not generated; the Administrator was asked for physician's orders for the Skilled Psychiatric Nurse visit completed from 01/19/23 through 02/09/23 to administer medications, as per previous certification periods; the Administrator stated that they must have a physician's order somewhere that had not been uploaded to the EMR; the Administrator was asked to provide the physician's order for the additional PT visits done from 02/06/23 through 02/28/23 and after the PT reevaluation on 03/01/23; the Administrator was not able to provide the physician's order for PT; the Administrator stated that a physician's order "must be in the office somewhere;" the Administrator stated that it was her responsibility to transmit/export Patient #1’s OASIS assessment within 30 days after completion and the Administrator stated she was the HHA's Case Manager and was doing the billing. 2) Review of Patient #2’s Physician's order, provided by the Administrator, dated, 12/29/22 documented, “Home Health to follow for SN (Skilled Nurse) to monitor pain status and PT to evaluate and treat." Review of Patient #2’s EMR documented a Start of Care OASIS assessment by a SN submitted on 12/30/22. Review of the assessment did not document that it was exported/transmitted as required; the assessment documented a SN visit frequency as one time and a PT visit frequency of three (3) times a week during the first week and then twice (2) a week for eight (8) weeks. Further review of the patient’s EMR lacks evidence of a physician's POC for the certification period from 12/30/23 to 02/27/23 for SN and PT visits. Review of Patient #2’s EMR reveals a lack of scheduled SN visit documentation for 01/03/23, 01/05/23, 01/10/23, 01/12/23, 01/17/23, 01/19/23 and 01/24/23. Review of Patient # 2’s EMR documented a Physical Therapy evaluation dated, 12/30/22 and subsequent Physical Therapist Assistant (PTA) visits from 01/02/23 through 02/20/23. Further review of the patient’s EMR lacks evidence of a POC for the PT visits. Review of Patient #2’s EMR documented an OASIS recertification by PT assessment, dated 02/27/23 that did not document that it was exported/transmitted as required with a PT visit frequency as one time for one (1) week then weekly for four (4) weeks. Further review reveals the lack of a Physician's POC for additional Physical Therapy visits. On 03/08/23 at 2:33 PM, during an interview, a side-by-side review of Patient #2’s EMR was conducted with the Administrator who confirmed that the patient’s Start of Care OASIS assessment completed on 12/30/22 and the Recertification OASIS assessment completed on 02/27/23 were submitted but had not been exported/transmitted as required; the Administrator stated Patient #2 was visited by the SN in January 2023 and the SN had not turned in the "visits notes," as of 03/07/23. On 03/08/23 at 2:59 PM, a joint telephone interview with Staff A, Physical Therapist Assistant and the Administrator was conducted; Staff A stated he visited Patient #2 on 03/02/23 and 03/06/23 but had not turned in the "Visit Notes." 3) Review of Patient # 3’s EMR documented a Start of Care OASIS assessment completed by a SN submitted on 11/25/22 that documented, under "Orders for disciplines, PT for evaluation and treat;" the assessment did not document that it was exported/transmitted as required. Further review of the patient’s EMR lacks evidence of the Physician's POC for the certification period from 11/25/22 to 01/23/23 for PT visits. Review of Patient #3’s EMR documented weekly SN visits completed from 11/28/22 through 12/28/22. Further review of the patient’s EMR lacks evidence of a Physician POC for SN visits for the certification period from 11/25/22 to 01/23/23. Review of Patient # 3’s EMR documented an OASIS Recertification assessment by PT dated, 01/23/23 that did not document that it was exported/transmitted as required. The assessment documented a PT visit frequency as two (2) times a week for two (2) weeks then weekly for six (6) weeks. Further review reveals the lack of a Physician POC for additional Physical Therapy visits. Furthermore, review of Patient #3’s EMR documented PT visits were completed from 02/01/23 through 02/28/23. Continued review of the patient’s EMR reveals a Speech Therapist (ST) Evaluation dated 11/25/22 that documented, under the discipline frequency, one (1) visit for evaluation, then twice (2) a week for two (2) weeks and weekly for two (2) weeks. Further review reveal the lack of a Physician POC for the ST evaluation and additional ST visits. Continued review reveals a ST visit was completed on 01/26/23, 01/31/23, 02/02/23, 02/06/23, 02/13/23, 02/28/23, 03/03/23 and 03/07/23. On 03/07/23 at 1:40 PM, a telephone interview was conducted with Patient #3 who stated he was getting Physical Therapist visits from the HHA twice a week. On 03/07/23 at 2:20 PM, during an interview, a side-by-side review of Patient #3’s EMR was conducted with the Administrator who stated that the patient’s OASIS assessment, done on 11/25/22 had not been exported/transmitted as required; stated that the Recertification OASIS assessment, done on 01/23/23 could not be exported/transmitted because the Initial OASIS assessment had not been exported/transmitted; the Administrator was asked to provide physician's orders for SN, PT and ST visits completed and stated she had to check if the physician's orders had been scanned in yet; the Administrator stated she checked the files and stated there was no physician's orders for Patient #3’s visits completed; the Administrator stated that the transmission of the patient’s OASIS assessment would generate the Physician’s POC; stated the HHA did not have a physician's POC for Patient #3 for the SN, the Physical Therapist and the Speech Therapist's completed visits; the Administrator stated she was behind doing the HHA's billing and added she was caught up to June 2022 with billing. On 03/08/23 at 3:01 PM, a joint telephone interview with Staff B, Registered Nurse and the Administrator; Staff B stated she works from home and was responsible to review the patient’s Start of Care OASIS assessments, Quality Assurance of the OASIS, review and coding the OASIS based on the physician documentation; Staff B stated once the coding is completed a POC is created, signed and the office sends it in to the physician for signature; Staff B stated had not finished (reviewing) Patient #3’s record yet and added she was waiting on a progress note from the physician; the Administrator stated Staff B was waiting on her to obtain the progress note from the physician; Staff B stated that the OASIS are transmitted within 15 to 20 days after completion and the Administrator added Patient #3’s assessment "fell through the cracks."

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on record review, and interview, the Home Health Agency (HHA) failed to ensure the development of and update to the patient’s Plan of Care (POC) for 3 of 3 sampled patients (Patient #1, #2 and #3). The findings included: 1) Review of Patient #1’s Electronic Medical Record (EMR) documented a Recertification Outcome And assessment Information Set (OASIS) by a Skilled Nurse (SN) assessment submitted on 01/12/23. Further review of the patient’s EMR lacks evidence of the Physician POC for the recertification period from 01/14/23 to 03/14/23. Review of Patient #1’s EMR documents a Skilled Psychiatric Nurse visit completed from 01/19/23 through 02/09/23 and the lack of a Physician POC for the visits. Continued review reveals the lack of the Skilled Psychiatric Nurse visit notes from the week of 02/12/23 to 03/05/23. Review of Patient #1’s EMR documents a physician's order, dated 02/02/23 for Physical Therapy (PT) evaluation and treatment. Further review reveals the lack of a physician's order for any additional Physical Therapy visits and the lack of a Physician POC. Review of Patient #1’s EMR documented a Physical Therapy evaluation dated, 02/06/23 and subsequent Physical Therapist Assistant (PTA) visits from 02/06/23 through 02/28/23. Review of Patient #1’s EMR documented a Physical Therapy Re-evaluation dated, 03/01/23; the lack of a physician's order for any additional Physical Therapy visits and the lack of a Physician POC. On 03/07/23 at 2:45 PM, during an interview, a side-by-side review of Patient #1’s EMR was conducted with the Administrator. who confirmed that the patient’s lack of a Physician's POC; the Administrator explained that once a patient had a completed OASIS assessment, it is coded, transmitted and generates a physician POC that is sent to the physician; the Administrator explained that Patient #1's recertification assessment was done on 01/12/23 and a Physician POC had not been created; the Administrator was asked for physician's orders for the Skilled Psychiatric Nurse visit completed from 01/19/23 through 02/09/23; the Administrator stated that the HHA must have a physician's order "somewhere that had not been uploaded to the EMR; the Administrator was asked to provide a physician's order for the additional PT visits done from 02/06/23 through 02/28/23 and visits after the PT re-evaluation on 03/01/23; the Administrator was not able to provide the physician's order for the PT visits; the Administrator stated that a physician's order "must be in the office somewhere;" the Administrator stated that it was her responsibility to transmit/export Patient #1’s OASIS assessment within the 30 days after completion. 2) Review of Patient #2’s physician order, provided by the Administrator, dated 12/29/22 documented, “Home Health to follow for Skilled Nurse (SN) to monitor pain status and Physical Therapy (PT) to evaluate and treat." Review of Patient #2’s EMR documented a Start of Care OASIS assessment by a SN submitted on 12/30/22. The assessment documented a SN visit frequency as one (1) time and PT visits frequency as three (3) times a week during the first week and then twice (2) a week for eight (8) weeks. Further review of the patient’s EMR lacks evidence of the Physician POC for the certification period from 12/30/23 to 02/27/23 for SN and PT visits. Review of Patient #2’s EMR reveals a lack of scheduled SN visit documentation for 01/03/23, 01/05/23, 01/10/23, 01/12/23, 01/17/23, 01/19/23 and 01/24/23. Review of Patient #2’s EMR documents a Physical Therapy evaluation dated, 12/30/22 and subsequent Physical Therapist Assistant (PTA) visits from 01/02/23 through 02/20/23. Further review of the patient’s EMR lacks evidence of a Physician POC for PT visits. Further review of Patient #2’s EMR documented an OASIS Recertification by PT assessment dated, 02/27/23 that documented the PT visit frequency as one (1) visit for one (1) week then weekly for four (4) weeks. Further review reveals the lack of a Physician POC for additional Physical Therapy visits. On 03/08/23 at 2:33 PM, during an interview, a side-by-side review of Patient #2’s EMR was conducted with the Administrator who confirmed that the patient’s Start of Care OASIS assessment completed on 12/30/22 and the Recertification OASIS assessment completed on 02/27/23 were submitted; the Administrator stated Patient #2 was visited by the SN in January 2023 and the SN had not turned in the visit notes, as of 03/07/23. On 03/08/23 at 2:59 PM, a joint telephone interview with Staff A, Physical Therapist Assistant and the Administrator was conducted; Staff A stated he visited Patient #2 on 03/02/23 and 03/06/23 but had not turned in the visit note. 3) Review of Patient #3’s EMR documented a Start of Care -OASIS assessment completed by a SN, submitted on 11/25/22 that documented, under orders for disciplines, "PT for evaluation and treat." Further review of the patient’s EMR lacks evidence of the Physician POC for the certification period from 11/25/22 to 01/23/23 for PT visits. Review of Patient #3’s EMR documented weekly SN visits completed from 11/28/22 through 12/28/22. Further review of the patient’s EMR lacks evidence of the Physician POC or SN visits for the certification period from 11/25/22 to 01/23/23. Review of Patient #3’s EMR documented an OASIS Recertification assessment by PT dated, 01/23/23 that documented PT visit frequency as two (2) times a week for two (2) weeks then weekly for six (6) weeks. Further review reveals the lack of a Physician POC for additional PT visits. Review of Patient #3’s EMR documented PT visits completed from 02/01/23 through 02/28/23. Continued review of Patient #3’s EMR revealed a Speech Therapist (ST) Evaluation dated 11/25/22 that documented, under the discipline frequency, one (1) visit for evaluation, then twice (2) a week for two (2) weeks and weekly for two (2) weeks. Further review reveals the lack of a Physician POC for ST evaluation and additional ST visits. The review reveals a ST visit completed on 01/26/23, 01/31/23, 02/02/23, 02/06/23, 02/13/23, 02/28/23, 03/03/23 and 03/07/23. On 03/07/23 at 1:40 PM, a telephone interview was conducted with Patient #3 who stated he was getting Physical Therapist visits from the HHA twice a week. On 03/07/23 at 2:20 PM, during an interview, a side-by-side review of Patient #3’s EMR was conducted with the Administrator who stated there was no Physician’s POC for Patient #3 for the Start of Care completed on 11/25/22 and for the Recertification assessment completed on 01/23/23. The Administrator was asked to submit physician's orders for SN, PT and ST visits completed and stated she had to check if the physician's orders had not been scanned in yet, stated she checked the files and stated there was no physician's orders for Patient #3’s visits completed. On 03/08/23 at 3:01 PM, a joint telephone interview with Staff B, Registered Nurse and the Administrator; Staff B stated she works from home and was responsible to review the patient’s Start of Care OASIS assessments, Quality Assurance of the OASIS, review and coding the OASIS based on the physician documentation; Staff B stated once the coding is completed a POC is created, signed and the office send it in to the physician for signature; Staff B stated that she had not finished (reviewing) Patient #3’s record yet and added she was waiting on a progress note from the physician; the Administrator stated Staff B was waiting on her to obtain the progress note from the physician and the Administrator added Patient #3’s assessment "fell through the cracks."