Every finding on record at Always Caring Home Care Services Inc

A re-certification survey was conducted on 04/15/2025. The Agency census was: L&CHHS - 94 LHHS - 36 PAS - 11 Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services PAS - Personal Assistance Services CMS - Centers for Medicare & Medicaid Services OASIS - Outcome and Assessment Information Set iQIES - Internet Quality Improvement and Evaluation System HHA - Home Health Agency

A re-certification survey was conducted on 04/15/2025. The Agency census was: L&CHHS - 94 LHHS - 36 PAS - 11 Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services PAS - Personal Assistance Services CMS - Centers for Medicare & Medicaid Services OASIS - Outcome and Assessment Information Set iQIES - Internet Quality Improvement and Evaluation System HHA - Home Health Agency

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 (A tool used by CMS to collect certain patient information) assessment to the CMS system within 30 days of completing the assessment of the patient for 38 out of 1440 of the assessments processed for the time-period reviewed of 4/14/2024 to 4/15/2025. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare and improve patient care failing to be reported to CMS in the required time frame. Findings included: Review of the HHA Error Summary Report for the time-period of 4/14/2024 to 4/15/2025 identified Error #-3330. The description for Error #-3330 read in part, “Record Submitted Late: The submission date was more than 30 days after M0090 (item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with this error was 38 assessments and the percentage of assessments with this error was 2.64% of assessments completed by the Agency. An interview was conducted with the Administrator on 04/17/2025 at approximately 3:00 PM. Surveyor reviewed the HHA Error Summary Report for the time-period of 04/14/2024 to 04/15/2025 with the Administrator. The Administrator stated the Alternate Administrator is responsible for ensuring OASIS assessments are submitted timely and tracking OASIS submissions. An interview was conducted with the Alternate Administrator on 04/24/2025 at approximately 2:00 PM. Surveyor reviewed the HHA Error Summary Report for the time-period of 4/14/2024 to 4/15/2025 with the Alternate Administrator. The Alternate Administrator stated she is responsible for ensuring that OASIS assessments are submitted timely. The Alternate Administrator stated late OASIS submissions occurred due to Agency nurses submitting documentation late. The Alternate Administrator stated that she has provided education to Agency nurses who struggle with submitting documentation timely and monitors and reminds Agency nurses to submit documentation.