Every finding on record at Baptist Health

On 01/21/25 at 11:35 AM, an entrance conference was conducted with Agency Representatives. The agency was informed that the purpose of the visit was to conduct a Medicare recertification survey for compliance with the Conditions of Participation for Home Health. The general nature of the survey process and expected length of survey were explained. On 01/24/25 at 11:45 AM, an exit survey was conducted with Agency Representatives. Preliminary findings of the survey were discussed. The Agency Representatives were given the opportunity to present additional information for the findings discussed. No additional information was presented.

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 a pre-survey review of the Agency's reports it was determined the Agency failed to encode and transmit Outcome and Assessment Information Set (OASIS) patient data within the required 30 days of the assessment completion date. This failed practice, if not corrected, could result in late submission of all assessments. Findings follow: Review of the "HHA (Home Health Agency) Error Summary by Agency Report" revealed a total of 161 assessments with error -3330 (Record Submitted Late) for the prior calendar year. Review of a document titled "PIP (Performance Improvement Plan) for Late OASIS Submissions" revealed the Agency identified issues that caused records to be submitted late. Documentation of "OASIS Late Submission Rate Percent" from October 2023 to October 2024 failed to provide evidence of measurable progress or sustained improvements since issues identified in May 2024. An interview on 01/24/25 at 12:05 PM with Agency Personnel #2 confirmed failure to submit assessments after completed within the required 30-day period.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, it was determined the Registered Nurse (RN) failed to supervise and assess the quality of care and services provided through on-site supervisory aide visits (SAV) every 14 days in 1(#5) of 2 (#5 and #6) current clinical records reviewed with Home Health Aide (HHA) services. This lack of supervision by the RN had the potential to place all patients receiving HHA services at risk for adverse outcomes due to possible delays in the discovery of noncompliance with the aide plan of care by the HHA or possible changes in the needs of the patient. Findings follow: Review of clinical record #5 with a SOC of 12/13/24 revealed a patient with a diagnosis of Pressure Ulcer of Left Heel Stage 2. A document titled “Home Health Plan of Care 12/13/24" revealed orders for Aide services. The Aide documented HHA services provided on a document titled “Aide Home Visit” and dated 12/16/24. The RN documented the first SAV on a document titled "SN (Skilled Nurse) Home Visit" and dated 01/06/2025 (7 days late). An interview on 01/23/25 at 3:15 PM with Agency Personnel #1 confirmed the failure to conduct supervisory aide visits within the required 14-day period.