Every finding on record at Oak Crest Village, Inc.

A re-certification survey of Oakcrest Village, Inc was conducted March 10 - 14, 2025. After reviewing the agency’s emergency preparedness program, plan, and policies and procedures, the agency was found to comply with all Conditions of Participation and related standards found at 42 CFR (Code of Federal Regulations) Part 484.102.

A recertification survey was completed at Oakcrest Village Inc., located in Baltimore, Maryland, on March 10 - 14, 2025. The survey included the request of administrative records and documentation. Interviews were conducted with patients, staff, the agency's administrator, and the clinical manager. Three home visits were conducted in conjunction with the physical therapist and registered nurse, and clinical manager. A total of 7 clinical records were randomly selected and reviewed during the survey. This represented the scope of services as follows: Skilled Nursing Services - 5 Home Health Aide - 1 Physical Therapy Services - 6 Occupational Therapy Services - 5 Findings in this report were based on all document reviews and interviews with the administrative staff. The agency's administrative was kept informed of the survey findings as the survey progressed. The exit conference was conducted with the administrative staff on March 14, 2025. The following requirements of 42 CFR Part 484 Home Health Regulations were not met.

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 records reviewed from March 1, 2024, to March 10, 2025, the agency failed to ensure timely submission of OASIS assessments to the CMS system. The findings include: A review of the agency’s Error Report 3330 revealed that 202 OASIS assessments were submitted late, exceeding the 30-day submission requirement.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Home health aides are members of the interdisciplinary team. They must report changes in the patient's condition to a registered nurse or other appropriate skilled professional and complete appropriate records required by the HHA. Failure to comply with regulations places patients at risk for inadequate health care. During interdisciplinary team meetings, all HHA staff involved in the patient's care must be present and, where appropriate, should contribute to any discussion regarding the patient's care. This did not occur. Findings include: 1. On 3/12/2025, while attending the agency's interdisciplinary team meeting (case conference), it was noted that no aide staff was present at the meeting. 2. A review of the agency's interdisciplinary meetings attendance for the past 2 months included meetings on 1/8,1/15,1/29,2/5,2/19,2/26,3/5/2025 had no Aides in attendance. 3. During an interview with the agency's administrative staff, it was confirmed that Aides do not currently participate in the interdisciplinary team meeting.