Every finding on record at Ameuro Home Health Inc

A re-certification survey was conducted on 12/03/2024. Agency’s Census L&C: 8 LHHS: 20 PAS: 25 Abbreviations L&C (Licensed and Certified Home Health Services) LHHS (Licensed Home Health Services) PAS (Personal Assistance Services)

A re-certification survey was conducted on 12/03/2024. Agency’s Census L&C: 8 LHHS: 20 PAS: 25 Abbreviations ADM (Administrator) Alt ADM (Alternate Administrator) DON (Director of Nursing) ADON (Alternate Director of Nursing) CMS (Centers for Medicare & Medicaid Services) CR (Clinical record) EMR (Electronic Medical Record) HHA (Home Health Agency) HHSC (Health and Human Services Commission) iQIES (Quality Improvement Evaluation System) L&C (Licensed and Certified Home Health Services) LHHS (Licensed Home Health Services) OASIS (Outcome and Assessment Information Set) PAS (Personal Assistance Services) POC (Plan of Care) PRN (As Needed) PT (Physical Therapy) RN (Registered Nurse) SEC (Secretary) SN (Skilled Nursing and/or Skilled Nurse) SOC (Start of Care) SR (Surveyor) Wk (Week) X (Times)

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 home health agency failed to 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 within 30 days of completing the assessment of the beneficiary for 59 of 109 assessments done. This failure did not allow the home health agency to systematically collect standardized data on the agency’s patient’s health status, to track patient’s progress through measures of quality of care and then report those data points to the CMS system for overall quality monitoring and reimbursement purposes. Findings Record review during pre-survey preparation on 12/02/2024 of IQIES Report entitled, “HHA Error Summary by Agency” (report ran from the dates of 12/01/2023 to 12/02/2024), revealed of the 109 assessments completed by the agency there were 59 assessments that produced error code number 3330 for the percentage of 54.13%. Error code number 3330 error description reads in part, “… -3330- Record Submitted Late: The submission date is more than 30 days…” During an interview with the Alt ADM/DON on 12/06/2024 at 5:52PM. SR inquired from Alt ADM/DON if the agency had any Review and Correct Reports and/or corrected transmission reports that could be reviewed for the 59 patient assessments done by the agency. Alt ADM/DON stated, “No. I thought [EMR] saved all the documents correctly. No. I don’t have them.” SR inquired further if the agency had any error alert reports from [EMR] that the documents were not saved correctly. Alt ADM/DON stated, “No. I do not.” During an interview with the Alt ADM/DON on 12/06/2024 at 5:55PM, the SR inquired, why there were so many missed, incorrect, and/or delayed OASIS reports that were submitted after the 30-day timeframe for the last year. The Alt ADM/DON did not answer the question, but stated, “I honestly didn’t know all of the errors would be counted like this.” Record review of administrative policy manual entitled “Administrator” reviewed date unknown page 2 of 3 reads in part, “… D. Being familiar with State and Federal regulations and arranging for Agency compliance with the same. E. Being responsible for familiarizing employees with State, Federal Regulations… F. Being responsible for the completion, keeping, and submission of such reports and records has required by State, Federal Regulatory Agencies…”