Every finding on record at Affinity Health Care, LLC

A recertification survey entrance conference was conducted on 10/28/24 at 10:50 a.m. The census was 42. Licensed and certified – 42 Licensed Home Health – 0 There were no deficiencies related to Emergency Preparedness.

A recertification survey entrance conference was conducted on 10/28/24 at 10:50 a.m. The census was 42. Licensed and certified – 42 Licensed Home Health – 0 Abbreviations included: OASIS – Outcome and Assessment Information Set QAPI- Quality Assessment Performance Improvement iQies – Internet Quality Improvement and Evaluation System CMS – Centers for Medicare and Medicaid Services

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 interview and record review, the agency failed to code and electronically transmit each completed OASIS (data collected as part of the comprehensive assessment) assessment to the CMS system within thirty days of completing the assessment of the beneficiary for 71 of 531 records submitted (13.37%). The agency did not code and electronically submit patient’s OASIS data to IQIES (electronic system used to transmit quality measures from the OASIS data collected during comprehensive assessments) within 30 days to track and evaluate changes in the patient’s health while admitted to home health services to help ensure quality healthcare for patients. This failure prevented the agency’s patient OASIS data from being made available to CMS for analysis of patient care performance. Findings included: Review of an IQIES Error Summary Report dated 10/28/23 to 10/28/24 generated by the surveyor during pre-survey preparation indicated the agency failed to code and electronically transmit 71 of 531 OASIS assessments data to the CMS system within thirty days of completing the assessment of the beneficiary. During an interview on 10/28/24 at 11:50 a.m., the Administrator said Staff J was the person responsible for submitting the OASIS assessments. The Administrator said the assessments were to be transmitted within 30 days of completion. He said he was aware that some assessments had been submitted late, but did not know how many. During an interview on 10/28/24 at 3:38 p.m., the Quality Assurance (QA) Coordinator said there had been problems with OASIS assessment date being submitted late. She said the late OASIS submissions were not addressed with a Performance Improvement Project. During an interview on 10/30/24 at 11:51 a.m., Staff J said she worked for the company contracted to provide billing services for the agency. Staff J said she was responsible for submitting the OASIS assessment data after it was completed by the agency. Staff J said she had notified the agency of late submissions periodically (unspecified) and had expressed concern about the late submissions in an email to the Administrator and Supervising Nurse a couple of months ago (unspecified). Staff J said she did not know why the agency was taking so long to complete the assessments and refer them to her for submission. Record review of an email dated 6/19/24, sent from Staff J to the agency Administrator and Supervising Nurse, indicated: · Subject: BYPASS: Timely Assessment Locking · Importance: High · We are getting more and more assessment locked beyond the 30-day timely submission date. Please make sure OASIS are being locked in under 23 days so they can be submitted in under 30 days. I submit every Wednesday so if one is locked Wednesday afternoon, it will be submitted the following Wednesday. · This is from today. 5 assessments were locked beyond 30 days. Record Review of an agency policy titled Timelines, reviewed 05/02/24, indicated all completed and encoded OASIS data will be transmitted within 30 days of the M0090 (the date the assessment is actually completed) date. Record Review of a report titled OASIS Error Detail Report, dated 10/28/24 and provided by the Administrator on 10/29/24 at 2:15 p.m., indicated: · April 2024 - 13 OASIS assessments were submitted more than 30 days after M0090 · May 2024 – 10 OASIS assessments were submitted more than 30 days after M0090 · July 2024 – 19 OASIS assessments were submitted more than 30 days after M0090 · August 2024 – 12 OASIS assessments were submitted more than 30 days after M0090 · September 2024 – 15 OASIS assessments were submitted more than 30 days after M0090