Every finding on record at Baptist Home Health Care

During the partial extended recertification survey conducted on 4/1/2024 through 4/4/2024 at Baptist Home Health Care, Emergency Preparedness was reviewed. The home health agency is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A partial extended recertification survey was conducted on 4/1/2024 through 4/4/2024 at Baptist Home Health Care. At the time of the survey, the home health agency was not in compliance with 42 CFR Part 484, Requirements 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 encode and electronically transmit each completed OASIS (Outcome and Assessment Information Set.) assessment to the Centers for Medicare and Medicaid Services, (CMS), regarding each beneficiary with respect to which information is required to be transmitted within 30 days of completing the assessment of the beneficiary. A review of The HHA Error Summary by Agency OASIS report was reviewed on 4/1/2024. The focus of this review was on one specific error, -3330, “Record Submitted Late: The submission date is more than 30 days after M0090 (Date Assessment Completed) on this new record. The criteria for this report is the prior calendar year. The home health agency had one assessment with error -3300. An interview was conducted with the administrator on 4/4/2024 at 10:00 AM. The administrator confirmed there was one incident with error -3300 on the oasis report, The HHA Error Summary by Agency Report and provided a copy of the notification to the agency.

During the partial extended recertification survey conducted 4/26/2021 thru 4/28/2021 at the Baptist Home Health Care branch office, a home health agency located at 1505 Merchants Way, Niceville, FL 32578, Emergency Preparedness was reviewed. This agency has a parent office located at 401 East Chase St, Suite 200, Pensacola, FL 32502. Baptist Home Health Care was found to be in compliance with Emergency Preparedness per CFR 42, Part 484.22, Condition of Participation for Home Health Agencies.

An unannounced partial extended recertification survey was conducted 4/26/2021 through 4/28/2021 at the branch office of Baptist Home Health Care, a home health agency located at 1505 Merchants Way, Niceville, FL 32578. This agency has a parent office located at 401 East Chase St., Suite 200, Pensacola, FL 32502. The Baptist Home Health Care Agency was not in compliance with 42 CFR Part 484, Requirements for Home Health Agencies.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and staff interview, the facility failed to ensure that skilled professional staff, maintained accurate clinical notes for 1 of 17 sample patients (Patient #5). The findings include: A record review for Patient #5 revealed skilled nurse clinical visit notes completed by Staff G, an agency Licensed Practical Nurse (LPN) documenting his/her findings on visits to the patient on 3/25/2021, 4/7/2021 and 4/15/2021. The clinical notes contained a section titled "Endocrine" with questions for the clinician to complete related to Diabetes and Diabetic signs/symptoms. The question, "Is Diabetic foot care routinely provided/" is marked "Yes" on all of the above referenced dates. The next question in this section "Lower extremities assessment" is marked "N/A patient bilateral above or below the knee amputation". The answers to these 2 questions were inconsistent as diabetic foot care cannot be provided to an amputated limb. No explanation or narrative comment could be found in the clinical notes to explain this inconsistency. Further review of the clinical record revealed no indication anywhere that the patient is either an above or below the knee amputee. Review of skilled nurse clinical visit notes completed by other agency clinicians reveal documentation in this same section of lower extremity assessments with statements such as "no lesions present". These assessments indicate the patient is not a lower extremity amputee, and that the feet were examined during these skilled nurse visits. Electronic documentation is used to record clinical findings during nursing visits. The program used is formatted with a series of pre-populated questions with "checkboxes" used to answer the questions. The program also allows for brief comments for some questions, as well as a "Narrative" section for the clinician to document more extensive comments or visit summary notes. An interview was conducted on 4/27/2021 at approximately 1:45 PM, with the agency Administrator, who confirmed Patient #5 is not an amputee, and that the skilled nurse visit notes dated 3/25/2021, 4/7/2021 and 4/15/2021 were inaccurate in indicating status as an amputee. She stated Staff G, LPN had probably inadvertently used the wrong response box on the electronic record. She stated Staff G would be educated on the proper way to document her findings going forward.