Every finding on record at Crossridge Comm Hospital Home Health

On 02/03/25 at 4:00 p.m., an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare Recertification Survey for the compliance with the Conditions of Participation for Home Health. On 02/05/25 at 4:00 p.m., an exit conference was conducted with Agency Representatives. Preliminary findings were discussed.

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 pre-survey review of the Agency's reports, agency documents, and staff interview it was determined the agency failed to transmit all comprehensive assessments within 30 days of its completion as required by CMS (Centers for Medicare and Medicaid Services) Conditions of Participation (CoP). This failed practice, if not corrected, could result in more late records submissions. Findings follow: A review of the HHA (Home Health Agency) Error Summary report with a report period of 01/01/2024 to 12/31/2024 showed there were 130 comprehensive records (20.38%) that had been submitted over 30 days after the completion of the assessment record as of 02/03/25. On 02/03/25, the Administrator was informed of this pre-survey report and given an opportunity to provide any further information and none was provided. On 02/05/25, the Administrator provided a policy and procedure titled, " Improving Network Performance" which documented, "... The agency collects, encodes and transmits OASIS data in accordance with all applicable regulations and laws, including the conditions of participation..."

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on Clinical Record Review, agency documents, and staff interview, it was determined the Skilled Nurse (SN), failed to include Oxygen (O2) during review of the patient's medications in 2 (#2 and #6) of 7 (#1-#7) clinical records reviewed. This failed practice posed a risk of potential harm for patients on census receiving oxygen therapy by inhibiting the Nurse and Physician's ability to make informed decisions regarding the patient's medication regimen related to potential adverse effects, drug interactions, significant side effects or significant drug interactions. Findings follow: Review of Clinical Record #2 with a start of care date of 01/08/25 revealed a patient with a diagnosis of Chronic Respiratory Failure and had an order for Oxygen at 2 lpm (liters per minute) as needed. There were 7 skilled nursing notes from 01/10/25 to 01/29/25 in which oxygen was documented as being utilized by the patient. There was no evidence that oxygen was checked against other medications for interactions or side effects. Review of Clinical Record #6 with a start of care date of 10/04/24 revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and had an order for continuous Oxygen at 3 lpm (liters per minute). There was no evidence that oxygen was checked against other medications for interactions or side effects. On 02/05/25, the Administrator was asked to provide any documentation that the oxygen was checked against other medications for interactions or side effects. The Administrator stated, "Our computer system checks the medications automatically, but oxygen is not included. I can tell you it's not there." On 02/05/25, the Administrator provided a policy and procedure titled, "Medication Management" which documented, ".... Medications include currently prescribed, over the counter, herbal remedies, vitamins, Oxygen, updrafts, and inhalers...The nurse will complete the Medication Interaction Report and forward to the ordering physician/s within one calendar day to resolve clinically significant medication issues..."