Every finding on record at Oracle Home Health Inc

Purpose of visit: Recertification survey The census was - 14 Licensed and Certified clients – 14 Licensed Home Health clients - 0 No deficiencies cited. The agency is in compliance with the conditions of participation for emergency preparedness.

Purpose of visit: Recertification survey The census was - 14 Licensed and Certified clients – 14 Licensed Home Health clients - 0 Abbreviations: CMS – Centers for Medicare and Medicaid Services OASIS – Outcome and assessment information set IQIES- Internet Quality Improvement and Evaluation System QAPI- Quality Assessment and Performance Improvement EMR- Electronic Medical Record LVN- Licensed Vocational Nurse RN – Registered Nurse DON- Director of Nursing / Supervising Nurse

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 agency failed to encode and electronically transmit each completed OASIS assessment (a tool used by CMS to collect and report patient information for quality improvement and monitoring) to the CMS system within 30 days of completing the patient’s assessment for 20 OASIS patients’ assessments submitted from 10/01/2023 to 12/31/2024. This failure prevented CMS from analyzing patient’s data and the agency’s performance in comparison to other agencies, which potentially placed patients at risk for substandard care due to inaccurate OASIS information. The surveyor reviewed the OASIS (a set of assessment data used to measure patient outcomes over specified time periods) error report in IQIES (Internet Quality Improvement and Evaluation System- the CMS system to track patient outcomes) on 2/10/2025 for period 10/01/2023 to 12/31/2024. The report revealed late submissions of OASIS patient assessment data greater than 30 days for 20 comprehensive patient assessments. The report included 20 patient names with late submissions. An interview was conducted with the Administrator during the entrance conference on 02/11/2025 at 10:40 AM. The surveyor reviewed the findings of the late OASIS patient assessment data transmissions to the Center for Medicare and Medicaid Services system via the IQIES system. The surveyor asked about the agency’s process for encoding and transmitting the OASIS. The Administrator stated that he transmitted the data when the OASIS was ready, after the nurse completed the assessments. The surveyor asked why the OASIS transmissions were late. The Administrator stated: “we figured out the problem.” The Administrator stated: “there was a delay when the patient was admitted and then they cancelled the service.” The Administrator stated: “I didn’t know the process either.” The Administrator stated the agency’s consultant came in January 2025 and found the problem. Record review of the agency QAPI manual on 02/11/2025 found the identification of the later OASIS transmissions in January 2025. Review of the entire manual and all QAPI documents provided found no evidence corrective actions were reviewed for effectiveness. An interview was conducted with the Administrator and the DON on 02/14/2025 at 11AM. The surveyor shared the findings of the QAPI review and the late OASIS submissions report. The Administrator stated “It’s the discharge OASIS that is delayed. It was a mistake. The EMR system had an error and sometimes the patient disappears. The Administrator stated: “80 percent of the late ones were discharges.” The surveyor asked how long the nurses had to submit the OASIS recertification assessments. The Administrator stated they have 5 days. The surveyor asked if the nurses were late submitting the finished assessments. The Administrator stated: “Yes.” The surveyor asked if the agency sent the assessments to a coding company for review after submission. The Administrator stated that they did. The surveyor asked what happened next. The Administrator stated the nurse made the corrections. The surveyor asked if there were delays in making and returning the assessments after the coding review. The Administrator stated there were. The surveyor asked if the agency had any evidence the quality assurance activities had improved the late transmissions. The Administrator stated they did not because the consultant just came in January 2025. Review of agency’s policy “8.10 Timelines” revision 1/29/2020 reads in part “Encoding and locking OASIS data for the state will be completed within seven (7) days of completion of the Comprehensive Assessment. Completed, encoded, and locked OASIS data will be transmitted within thirty (30) days of the M0090 date.”

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure 2 (Patient 1 and 2) of 7 had an update to the comprehensive assessment in the last 5 days of every 60 days beginning with the start-of-care date by a qualified nurse or therapist. This failure meant patients plan of care was not updated to reflect the most current needs. Patients were potentially subjected to poor quality care. Record review on 02/13/2025 revealed Patient 1 had a start of care date of 08/15/2024. The certification period review 12/13/2024 to 02/10/2025 revealed no update to the comprehensive assessment was completed for Patient 1. Review of Patient 1s schedule revealed a comprehensive assessment was due on 02/09/2025. The comprehensive assessment was due to be updated from 02/05/2025 to 02/10/2025. The Plan of Care for Patient 1 documented diagnoses of Acute Bronchitis (Inflammation of the lungs bronchial tubes), Asthma Acute Exacerbation (a sudden and severe worsening of airway inflammation and narrowing), Hypertension (high Blood Pressure), Depression (mental health disorder characterized by persistent feeling of sadness, hopelessness, and loss of interest in activities), and Dementia (impairment of brain functions such as memory loss and judgement. Nursing visits weekly for 9 weeks were ordered on the Plan of Care. Record review on 02/13/2025 revealed Patient 2 had a start of care date of 12/15/2024. The certification period reviewed 12/12/2024 to 02/09/2025 revealed no update to the comprehensive assessment was completed for Patient 2. Review of Patient 2s schedule revealed a comprehensive assessment was scheduled on 02/09/2025. The comprehensive assessment was due to be updated from 02/04/2025 to 02/09/2025. The Plan of Care for Patient 2 documented diagnoses of Hypertension (high Blood Pressure), Cerebral Infarction (blood flow to the brain is interrupted leading to brain damage), Atrial Fibrillation (irregular often rapid heart rate that causes poor circulation), Use of Anticoagulants (medications to slow or prevent blood clotting), altered mental status (a change in a person’s mental function including awareness, attention, or consciousness), and Systemic Lupus Erythematosus (immune system attacks health tissues and organs). Nursing visits weekly for 9 weeks were ordered on the Plan of Care. An interview was attempted with RN A who was scheduled for Patient 1 and Patient 2’s comprehensive assessments on 02/09/2025. The surveyor called RN A on 02/13/2025 at 4:00PM and sent a text message with business card and request for a call back and 02/13/2025 at 4:07PM via text message. No return call or message was received by the exit on 02/14/2025. An interview was conducted with the Administrator and DON on 04/14/2025 at 10:40 AM. The surveyor reviewed the findings of the record reviews and lack of timely updates to the comprehensive assessments for Patient’s 1 and 2. The Administrator reviewed the electronic medical records for Patient 1 and Patient 2 and stated he did not see completed assessments that were scheduled to RN A and due on 02/09/2025. The surveyor asked what the potential harm to the patients were when the comprehensive assessments were not updated timely. The Administrator stated: “the LVN is scheduled to see the patients today and she may not have the updated orders.” The Administrator explained the comprehensive assessments are completed and the new Plan of care was generated from the assessments. The DON nodded her head in agreement. The Administrator stated he would talk to RN A about the lack of timely updates to the comprehensive assessments. Review of agency’s policy “8.10 Timelines” revision 1/29/2020 reads in part “Recertification / comprehensive reassessments will be completed at no earlier than 5 days prior to the end of the certification period (56th through the 60th day).”