Every finding on record at A C T Home Health Inc

A recertification survey entrance conference was conducted on 05/01/2024. The census was: LCHHS: 19 LHH: 0. Abbreviations: Adm Asst – Administrative Assistant ADON – alternate director of nurses Alt Adm – Alternate Administrator Alt DC - Alternate Disaster Coordinator LCHHS - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services PM - Post meridiem

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on record review and interview, the agency's written emergency preparedness and response plan failed to include a continuity of operations business plan which addressed emergency financial needs, essential functions for patient services, critical personnel and how to return to normal operations as quickly as possible in three of three years reviewed (2021, 2022 and 2023). This failure meant the agency lacked organized preparation and planning for patient care and services in the event of a disaster and could affect the agency's ability to provide care and services to patients during and after a disaster. Findings included: Record review of the agency’s two emergency preparedness binders did not include a continuity of operations business plan which addressed emergency financial needs, essential functions for patient services, critical personnel and how to return to normal operations as quickly as possible. Interviews were conducted with the Alt Adm/ADON/Alt DC on 05/08/2024. At 1:00 PM, the Alt Adm/ADON/Alt DC stated: She was the Alt DC. At 2:29 PM, the Alt Adm/ADON/Alt DC stated the agency did not have a continuity of operations business plan and was unaware it was required. The Adm and the Alt Adm were responsible for ensuring all EP requirements were met by the agency.

A recertification survey entrance conference was conducted on 05/01/2024. The census was: LCHHS: 19 LHH: 0. ABBREVIATIONS: % - percent # - number Adm Asst – Administrative Assistant ADON – alternate director of nurses Alt Adm – Alternate Administrator Alt DC - Alternate Disaster Coordinator AM - Ante meridiem CMS - Centers for Medicare & Medicaid Services COO - Chief Operations Officer HHA – home health agency IQIES - Internet Quality Improvement and Evaluation System LCHHS - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services OASIS - Outcome and Assessment Information Set PM - Post meridiem RN - registered 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 electronically transmit completed OASIS (a standardized data set that measures quality and outcomes of home health patients) assessments to the CMS system for all Medicare patients within 30 days of completing the OASIS assessment of the beneficiary (patient) for 5.84% (15 of 257) of assessments transmitted during the one-year period of 04/30/2023-04/30/2024. This failure prevented the agency’s patient data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. Findings included: During pre-survey activity on 04/30/2024, the surveyor reviewed the agency OASIS report titled, “HHA Error Summary by Agency” from IQIES (an internet-based system that includes survey and certification functions) for the one-year period of 04/30/2023-04/30/2024. The error summary report read in part… “…Error -3330 Record Submitted Late: The submission date is more than 30 days after M0090 [date of the assessment]… # of Assessments with Error… 15… % of Assessments with Error… 5.84%...” In an email received on 05/07/2024 at 11:46 AM, the COO stated the Adm Asst was responsible for submitting OASIS assessments to CMS until 01/01/2024. Beginning 01/01/2024, she (the COO) was responsible for submitting OASIS assessments to CMS. An interview was conducted with the Adm Asst on 05/07/2024 at 2:50 PM. The surveyor reviewed the error summary report which included five OASIS assessments submitted late before 01/01/2024. The Adm Asst stated she submitted OASIS assessments for assessments completed in the prior electronic medical record vendor, but the agency changed vendors at the beginning of 2024 and the COO was then responsible for submitting OASIS assessments. She (the Adm Asst) submitted five OASIS assessments late. Four of the assessments had OASIS questions incorrectly answered by RNs which had to be corrected and resulted in submission dates past 30 days of completion. She forgot to submit the one remaining assessment within the required timeframe. Five OASIS assessments were submitted late before 01/01/2024. An interview was conducted with the COO on 05/07/2024 at 1:15 PM. The surveyor reviewed the error summary report which included ten OASIS assessments submitted late after 01/01/2024. The COO stated she submitted OASIS assessments to CMS weekly but some were submitted past 30 days of completion . There were issues when the agency changed electronic medical record vendors. The assessments were submitted but did not transmit due to a problem with the agency’s facility identification #. She had to obtain an IQIES submitter identification # which caused submission delays in the first week of 01/2024. The agency also re-educated the RNs on completing assessments timely. Ten OASIS assessments were submitted late after 01/01/2024. An interview was conducted with the Alt Adm/ADON on 05/08/2024 at 12:40 PM. The surveyor reviewed the error summary report and the Alt Adm/ADON stated: The COO was responsible for submitting OASIS assessments to CMS. She was unaware the agency was not following its policy on OASIS submissions to CMS and did not know why the assessments were not submitted within 30 days of completion. The agency changed electronic medical record vendors in early 2024 and the transition had been difficult and may have contributed to late submissions. Agency policy titled, “Data Entry/Transmission of OASIS Information – 2.6” (undated) read in part, “…PURPOSE: To ensure accurate and timely data entry of all Outcomes and Assessment Information Set (OASIS) patient information… PROCEDURE… 7. The Administrator must designate two (2) employees that will possess the Agency PASSWORD and knowledge of how to electronically transmit OASIS data to the State at least monthly or within 30 days of the assessment date of the beneficiary… 8. The OASIS information must be electronically transmitted with accurate, complete, encoded and locked OASIS data for each patient to the State Agency at least monthly…”