Every finding on record at Mederi Caretenders

A Federal Emergency Preparedness survey was conducted at Mederi Caretenders, a home health agency on 4/15/2024 and 4/16/2024. The agency was in compliance with the Code of Federal Regulations (CFR) 42, Part 484.22, Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted at Mederi Caretenders, a home health agency on 4/15/2024 and 4/16/2024. The agency was not in compliance with the Code of Federal Regulations (CFR) 42, Part 484, 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 review of the agency's HHA Error Report for the previous 12 months, it was determined the agency failed to transmit Oasis data within 30 days of completing the assessment. Findings Include: Review of the HHA Error Report for the previous 12 months, run 4/12/2024, revealed 439 Oasis assessments were not transmitted with 30 days of completing the Oasis assessment for/ the beneficiaries (39.1 percent of transmissions). On 4/16/2024 an interview with the Home Health Agency’s Executive Director confirmed Client assessments were late being sent to Oasis and revealed that when staff are completed with the assessments, they are sent to the corporate office for further auditing and that may be where the assessments are held up prior to submission to Oasis. She did confirm that the assessments should be completed and submitted electronically within thirty days. On 4/16/2024 the Executive Director provided a non named policy with a signature and date of 1/23/2024. The directive/policy revealed; The Executive Director educated all staff on proper OASIS data capture and timely transmission to state agencies within 30 days utilizing Home Health Policy #7.002 OASIS Data Capture, Transmission, Verification, Display and Reports during a mandatory staff meeting held 11/28/2023. The directive further revealed the Executive Director/Designee and QR supervisor will facilitate individual clinician counselling for lack of adherence with timeframe expectations, as applicable. For all OASIS submitted beyond 30 days, an occurrence report will be completed by the Executive Director/Designee. The Executive Director confirmed she did not have an occurrence report for review. The Executive Director did not have an specific policy and procedure related to assessment submission to Oasis.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure Physical Therapy and Occupational therapy initial visits were conducted timely and per the plan of care for two of thirteen sampled patients/clients reviewed, (#5, and #8). Findings included: 1. On 4/16/2024 Client #5’s electronic medical record was reviewed. Review of the Home Health Certification and Plan of Care (document 485), revealed the client had a referral date on 3/12/2024 and a Start of Care date on 3/14/2024. The Client was picked up from the Home Health agency for Skilled Nursing Services and Physical Therapy Services. Review of the Plan of Care and Order sheet dated and signed by a Registered Nurse, revealed Physical Therapy ordered for frequency of visits to include; Effective date 3/17/2024 for one time a week for one week. Review of the care visit calendar revealed the first Physical Therapy visit was not conducted until 3/21/2024, (four days after the effective date, and seven days after the Start of Care date). An interview with the Executive Director on 4/16/2024 confirmed Physical Therapy did not assess and start their services in a timely manner and she at this time is in the process of hiring more therapy staff. She confirmed the visit should have happened on the effective date 3/17/2024 or one or two days later at the most. 2. On 5/16/2024 Client #8’s electronic medical record was reviewed. Review of the Home Health Certification and Plan of Care (document 485), revealed the client had a referral date on 2/29/2024 and a Start of Care date on 2/29/2024. Client #8 was picked up from the Home Health agency for Skilled Nursing Services, Physical Therapy Services, and Occupational Therapy Services. Review of the Plan of Care and Order sheet dated and signed by a Registered Nurse on 2/29/2024, revealed Physical Therapy and Occupational Therapy ordered for frequency of visits to include; Effective date 3/3/2024 for 1 time a week for six weeks, one time a week for every two weeks. Review of the care visit calendar revealed the first Physical Therapy and Occupational Therapy visit was not conducted until 3/6/2024, (three days after the effective date). An interview with the Executive Director on 4/16/2024 confirmed Physical Therapy did not assess and start their services in a timely manner and she at this time is in the process of hiring more therapy staff. She confirmed the visit should have happened on the effective date 3/6/2024 or one or two days later at the most. The Executive Director did not have a specific policy and procedure related to accountability and frequency of home visits for both Physical Therapy and Occupational Therapy.