Every finding on record at Armonia Home Health Care Agency LLC

An Entrance Conference was conducted on 06/18/2024 with the Administrator/Supervising Nurse, the Alternate Administrator, the Alternate Supervising Nurse and the Office Director at 1:50 PM. The Agency representatives were informed the purpose of the survey was a Recertification survey. Written information regarding "What to Expect During Your Agency's Survey" was provided. The Agency census was: L&CHHS - 83 An Exit Conference was conducted on 06/20/2024 with the Administrator/Supervising Nurse, the Alternate Administrator, and the Office Director at 3:45 PM. The Agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations/Acronyms/Definitions: L&CHHS - Licensed and Certified Home Health Services CMS - Centers for Medicare & Medicaid Services OASIS - Outcome and Assessment Information Set iQIES - Internet Quality Improvement and Evaluation System HHA - Home Health Agency OASIS - A tool used by CMS to collect certain patient information.

An Entrance Conference was conducted on 06/18/2024 with the Administrator/Supervising Nurse, the Alternate Administrator, the Alternate Supervising Nurse and the Office Director at 1:50 PM. The Agency representatives were informed the purpose of the survey was a Recertification survey. Written information regarding "What to Expect During Your Agency's Survey" was provided. The Agency census was: L&CHHS - 83 An Exit Conference was conducted on 06/20/2024 with the Administrator/Supervising Nurse, the Alternate Administrator, and the Office Director at 3:45 PM. The Agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations/Acronyms/Definitions: L&CHHS - Licensed and Certified Home Health Services CMS - Centers for Medicare & Medicaid Services OASIS - Outcome and Assessment Information Set iQIES - Internet Quality Improvement and Evaluation System HHA - Home Health Agency OASIS - A tool used by CMS to collect certain patient information.

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 assessment to the CMS system, within 30 days of completing the assessment of the patient for 82 of 483 assessments processed for the time-period reviewed of 05/12/2023 to 12/31/2023. 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: The HHA Error Summary Report, retrieved from the iQIES website for the time-period of 05/12/2023 to 12/31/2023 was reviewed. Review of the HHA Error Summary Report for the time-period of 05/12/2023 to 12/31/2023 identified Error #-3330. The description for Error #-3330 read in part, “Record Submitted Late: The submission date is 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 82 assessments and the percentage of assessments with this error was 16.98% of assessments completed by the Agency. An interview was conducted with the Administrator/Supervising Nurse on 06/20/2024 at 12:45 PM. The HHA Error Summary Report for the time-period of 05/12/2023 to 12/31/2023 was reviewed with the Administrator/Supervising Nurse. The Administrator/Supervising Nurse stated this delay in submission occurs when Agency registered nurses do not turn in documentation timely. The Administrator/Supervising Nurse stated the Agency frequently educated Agency nurses on timely submission of documentation. The Administrator/Supervising Nurse stated the Registered Nurse A is also coming into the office more frequently to assist the Administrator with ensuring OASIS assessments are submitted timely. The Administrator/Supervising Nurse stated an Agency QA Representative is also assisting in tracking to ensure OASIS are transmitted and encoded in a timely manner. Review of the Agency's policy and procedure manual revealed a policy titled "OASIS Collecting, Encoding and Transmitting," dated 01/10/2021, which read in part, "…The Agency must encode and transmit each completed OASIS assessment to the CMS system, for each beneficiary with respect to which information is required to be transmitted within 30 days of completing the assessment of the beneficiary."