Initial Comments:
Based on the findings of an onsite unannounced initial Medicare certification survey completed on January 14, 2022, Care In Action Home Healthcare Agency LLC, was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced initial Medicare certification survey completed January 14, 2022, Care in Action Home Healthcare Agency LLC, was found NOT to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.
Plan of Correction:
484.45(c) STANDARD
Transmittal of OASIS data
Name - Component - 00
Standard: Transmittal of OASIS data. An HHA must-
Observations:
Based on review of Clinical Records, and interview with the administrator, it was determined that the agency failed to update comprehensive assessments at least every 60 days for two, (2), of seven (7) Clinical Records, (CR), reviewed. (CR # 1, and 2).
On January 20, 2022 at approximately 1:00 p.m., a review of Centers for Medicare & Medicaid Services Outcome and Assessment Information Set OASIS-D Guidance Manual Effective January 1, 2019, Subtitled, "Time Points OASIS," revealed that, "Data are collected at the following time points:
Start of care Resumption of care following inpatient facility stay Recertification within the last five days of each 60-day recertification period Other follow-up during the home health episode of care Transfer to an inpatient facility Death at home Discharge from agency."
A continued review revealed under Subtitle, "Response-Specific Instructions-Response 4: This comprehensive follow-up assessment is conducted during the last five days of the 60-day certification period and is completed to continue the patient ' s services for an additional 60 day episode of care."
1. On January 13, 2022, at approximately 12:30 p.m., a review of CR #1's "Recertification of Continued Need for Care," dated from July 9, 2021, to September 6, 2021, revealed a Start of Care on March 11, 2021. There were no recertification records for review from September 6, 2021 to November 2021, and from November 2021, to January 2022, (greater than 120 day gap). A new recertification and Plan of Care was submitted for January 13, 2022 to March 13, 2022. A review of an agency document titled, "Agency Scheduled Tasks," revealed that on September 6, 2021, OASIS-D1 recertification was, "not yet started."
2. On January 13, 2022, at approximately 1:00 p.m., a review of CR #2's document titled , "Agency Scheduled Tasks," revealed a start of care on, October 28, 2019. The Agency Scheduled Tasks, also revealed that the CR #2's last OASIS-D1 was exported on February 10, 2020 as a Discharge. Further review revealed that on April 12, 2021, an OASIS start of care was, "saved." On June 4, 2021, the OASIS Recertification was not started. On October 1, 2021, non-OASIS Recertification was not started. From June 4, 2021 until January 12, 2022, there was no evidence that an OASIS had been exported. A new recertification and Plan of Care was submitted for January 13, 2022 to March 13, 2022.
On January 14, 2022, at approximately 3:00 p.m., in an exit interview with the Administrator, it was confirmed that the agency had failed to collect data and submit the OASIS at the Time Points recommended as per OASIS-D Guidance Manual.
Plan of Correction:The Director of Nursing participated in an in-service training on the Centers for Medicare & Medicaid Services Outcome and Assessment Information Set OASIS-D Guidance Manual Effective January 1, 2019, Subtitled, "Time Points OASIS" on January 18, 2022. The Director of Nursing shall be responsible for the collection of data and the submission of the OASIS at the Time Points recommended as per OASIS-D Guidance Manual.
The Administrator shall be responsible for monitoring and assuring that the Director of Nursing submits and updates all comprehensive assessments at least every 60 days.
484.55(b) STANDARD
Completion of the comprehensive assessment
Name - Component - 00
Standard: Completion of the comprehensive assessment.
Observations:
Based on review of Clinical Records, and interview with the administrator, it was determined that the agency failed to maintain standards for completion of the comprehensive assessment for (2), of seven (7) Clinical Records, (CR), reviewed. (CR # 1, and 2).
On January 20, 2022 at approximately 1:00 p.m., a review of Centers for Medicare & Medicaid Services Outcome and Assessment Information Set OASIS-D Guidance Manual Effective January 1, 2019, Subtitled, "Time Points OASIS," revealed that, "Data are collected at the following time points:
Start of care Resumption of care following inpatient facility stay Recertification within the last five days of each 60-day recertification period Other follow-up during the home health episode of care Transfer to an inpatient facility Death at home Discharge from agency."
A continued review revealed under Subtitle, "Response-Specific Instructions-Response 4: This comprehensive follow-up assessment is conducted during the last five days of the 60-day certification period and is completed to continue the patient ' s services for an additional 60 day episode of care."
1. On January 13, 2022, at approximately 12:30 p.m., a review of CR #1's "Recertification of Continued Need for Care," dated from July 9, 2021, to September 6, 2021, revealed a Start of Care on March 11, 2021. There were no recertification records for review from September 6, 2021 to November 2021, and from November 2021, to January 2022, (greater than 120 day gap). A new recertification and Plan of Care was submitted for January 13, 2022 to March 13, 2022. A review of an agency document titled, "Agency Scheduled Tasks," revealed that on September 6, 2021, OASIS-D1 recertification was, "not yet started."
2. On January 13, 2022, at approximately 1:00 p.m., a review of CR #2's document titled , "Agency Scheduled Tasks," revealed a start of care on, October 28, 2019. The Agency Scheduled Tasks, also revealed that the CR #2's last OASIS-D1 was exported on February 10, 2020 as a Discharge. Further review revealed that on April 12, 2021, an OASIS start of care was, "saved." On June 4, 2021, the OASIS Recertification was not started. On October 1, 2021, non-OASIS Recertification was not started. From June 4, 2021 until January 12, 2022, there was no evidence that an OASIS had been exported. A new recertification and Plan of Care was submitted for January 13, 2022 to March 13, 2022.
On January 14, 2022, at approximately 3:00 p.m., in an exit interview with the Administrator, it was confirmed that the agency had failed complete the comprehensive assessment and maintain standards to collect data and submit the OASIS at the Time Points recommended per the OASIS-D Guidance Manual.
Plan of Correction:The Director of Nursing participated in an in-service training on the Centers for Medicare & Medicaid Services Outcome and Assessment Information Set OASIS-D Guidance Manual Effective January 1, 2019, Subtitled, "Time Points OASIS" on January 18, 2022. The Director of Nursing shall be responsible for the collection of data and the submission of the OASIS at the Time Points recommended as per OASIS-D Guidance Manual.
The Administrator shall be responsible for monitoring and assuring that the Director of Nursing submits and updates all data that are collected at the following time points:
Start of care, Resumption of care following inpatient facility stay, Recertification within the last five days of each 60-day recertification period, Other follow-up during the home health episode of care, Transfer to an inpatient facility, Death at home, or Discharge from the agency.
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