Every finding on record at Omega Home Healthcare LLC

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 4/29/24 to 4/30/25 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 4-29-25 to 4-30-25 a recertification survey was conducted. This resulted in a partial extended survey at Omega Home Health Care, LLC. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. Unduplicated census previous 12 months: 13 Total home visits conducted: 1 List Hours of Operation: 8 a.m. to 5:00 p.m. List total number of records reviewed: 7

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 documentation and interview, the facility failed to report all OASIS data collected in accordance with federal regulations. Total number of records submitted beyond the 30 days was six, which equaled 12.50% of the assessments submitted. Findings include: On the HHA Error Summary by Agency report period of 3/1/24 to 3/14/25, the agency had an error code of -3330: record submitted late. The description included the submission was more than 30 days after completion on the new record. During an interview on 5/1/25 at 4:03 p.m., the director of nursing (DON) stated the agency's normal OASIS assessment process was to have the licensed nurse complete in the patient's electronic medical record and then the executive manager or specific designated office staff would transmit. The DON confirmed agency staff coded one assessment incorrectly and were simply late with the rest. The agency policy Oasis Implementation dated 9/1/19, identified the facility will electronically transmit accurate, completed, encoded and locked data for each patient to the state agency or CMS OASIS contractor within thirty days of date assessment is completed.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on observation, interview and document review, the agency failed to ensure a registered nurse (RN) conducted an initial assessment to determine the immediate care, and support needs forty-eight hours from the initial referral date for 1 of 7 (P6) patients reviewed for appropriate and timely start of care. Findings include: P6's electronic medical record (EMR) and plan of care (POC) with certification dates of 12/5/24 to 2/23/25 identified a referral date of 12/5/24 and state of care (SOC) date of 12/26/24. P6's EMR lacked evidence of provider notification and documentation as to why the initial admit wasn't completed within forty-eight hours of referral. When interviewed on 4/30/25 at 2:05 p.m., the director of nursing (DON) stated the expectation was for agency staff to complete an initial patient comprehensive assessment and care plan within 48 hours after their referral date to ensure patient safety and care needs. The DON stated this was difficult at times related to referrals with incomplete patient information coming from county agencies and not being able to schedule the initial assessment with the patient themselves. The DON stated if staff are unable to initiate assessment and plans of care within 48 hours for whatever reason, the expectation was the patient's physician was notified and to get an order for a new SOC date. The facility policy Comprehensive assessment dated 9/1/2019, identified the initial assessment must be held either within 48 hours of referral or within 48 hours of the individual’s return home, or on the physician-ordered start of care date.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure a patient's plan of care was reviewed by a physician within 60 days for 1 of 7 patients (P7) whose records were reviewed. Findings include: P7's Plan of Care (POC) certification period of 1/17/25 to 3/17/25, identified a start date of 1/17/25 and diagnoses of an unspecified open wound on his left lower leg, diabetes type 2 and unspecified malnutrition. P7's medical record lacked evidence his POC was reviewed and signed by his physician. When interviewed on 4/30/25 at 2:05 p.m., the director of nursing (DON) stated her expectation was a patient's assessments and new POC were to be completed by days one to five of the last days of the patient's current certification period and when complete it should be sent to the patient's physician for review and signature. The DON stated clinical management usually tracks the process and would make attempts to reach out to the physician if they did not receive the signed POC back and then document their attempts. The DON stated this process was missed for P7. The facility policy Physician Orders dated 9/1/2019, identified physician orders must be forwarded to the physician within 7 days of client admission. The policy also identified all patients medically directed plans of care must be reviewed, renewed and signed by the physician within the specified time frames for home health care and at least every sixty days.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure ordered services were provided in accordance with professional standards for 1 of 1 (P7) reviewed for wound care. Findings include: P7's Plan of Care (POC) certification period of 1/17/25 to 3/17/25, identified a start of care (SOC) date of 1/17/25 and diagnoses of an unspecified open wound on his left lower leg, diabetes type 2 and unspecified malnutrition. P7's POC included physician treatment orders for wound care and wound assessment with every visit. P7's nurse visit schedule indicated he was seen for services by an agency registered nurse (RN) seventeen times between his SOC date of 1/17/25 and the healing of his wound and discharge date of 3/7/25. P7's medical record lacked evidence his wound was assessed with any RN visit per order. When interviewed on 4/30/25 at 2:05 p.m., the director of nursing (DON) stated her expectation would be patient treatments are completed per physician order and if staff are unable or the patient refuses this should be documented in the patient record and communicated with the provider. The DON stated her expectation and best practice for wound care included assessment using observation for signs and symptoms of infection and measuring to determine progress towards healing or worsening to enable the patient's care team to determine if the current treatment is effective or needs to be changed. The DON confirmed this process was missed for P7. The facility policy Wound Care dated 3/8/21, identified Wound care is administered per physician’s order and acceptable professional standards of practice and includes measuring wound width, length and depth, assessing wound bed and surrounding skin, checking for drainage, pain and odor. The policy also identified observations and assessments made during wound treatment should be documented in the patient medical record.

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 3/20/23-3/22/23 during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 3/20/23-3/22/23, a recertification survey was conducted. This resulted in a partially extended survey at Omega Home Healthcare LLC. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. Unduplicated census previous 12 months: 37 Total home visits conducted: 0 (no home visits scheduled during time of survey) List Parent Location visited, including the addresses as verified while on site: Omega Home healthcare 1335 Corporation Center Curve Eagan, MN List Hours of Operation: 8 a.m. to 5 p.m. List total number of records reviewed: 6

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure clients plan of care was reviewed by a physician within 60 days for 4 of 6 clients (P1, P2, P3, P6) whose records were reviewed. P1’s Plan of Care (POC) certification date 9/7/22- 11/5/22, indicated P1's start of care was on 1/140/22, and P1 had diagnoses of diabetes, kidney disease, and obesity. P1's POC further indicated it was reviewed and signed by the physician on 1/4/23, which was 67 days late. P2’s POC certification date 11/2/22- 3/1/23, indicated P2's start of care was on 11/2/22 and P2 had diagnoses of rib fractures, ankle fracture, anxiety and alcohol abuse. P1's POC lacked indication it was reviewed or signed by a physician. P2's POC certification date 1/1/23- 3/1/23, lacked indication P2's POC was reviewed or signed by a physician. P3’s POC certification date 12/5/21-2/2/22, indicated P3's start of care was on 12/16/19, and P3 had diagnoses of alcohol abuse and tremor. P3's POC further indicated it was reviewed and signed by the physician on 8/1/22 which was 153 days late. P3’s POC certification date 2/3/22-4/3/22, was reviewed and signed by the physician on 8/1/22, which was 114 days late. P3’s POC certification date 4/4/22- 6/2/22, was reviewed and signed by the physician on 8/1/22, which was 64 days late. P6’s POC certification date 6/7/22-8/5/22, indicated P6's start of care was on 6/7/22 and P6 had diagnoses of Darier's disease (skin disorder). P6's POC lacked indication it was reviewed or signed by a physician. When interviewed on 3/22/23, at 10:00 a.m. the Director of Clinical Services (DCS) stated nurses complete the assessments that are incorporated into the patients POC. The POC are then put together and sent out to the physician for review and signature. This was completed by the clinical management services located in the corporate building. DCS further stated nursing does not track or review when or if a patient’s POC was reviewed or signed as there are orders for services provided on the start of care order. When interviewed on 3/22/23, at 11:55 a.m. the administrator stated she expected a patient’s POC to be reviewed and signed within 2 weeks of the POC being generated. The administrator acknowledged delays with physicians reviewing and signing POCs. The administrator expected staff to be tracking and following up with providers to ensure POCs are signed timely to ensure patients received care and services needed. A facility policy titled Care Planning and Coordination of Services revised 3/18/21, directed the individualized plan of care to be reviewed ad revised by the patient’s physician no less frequent than every 60 days.