Every finding on record at Ayuda Home Health Care Services LLC

An Entrance Conference was conducted on 08/07/2024 with the Alternate Administrator, the Licensed Vocational Nurse/Biller, the Clerk and via telephone with the Administrator and Supervising Nurse at 9:40 AM. 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 - 28 PAS - 0 An Exit Conference was conducted on 08/09/2024 with the Administrator, the Alternate Administrator/Alternate Supervising Nurse, the Supervising Nurse, the Licensed Vocational Nurse/Biller, and the Clerk at 12:30 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: L&CHHS - Licensed and Certified 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

An Entrance Conference was conducted on 08/07/2024 with the Alternate Administrator, the Licensed Vocational Nurse/Biller, the Clerk and via telephone with the Administrator and Supervising Nurse at 9:40 AM. 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 - 28 PAS - 0 An Exit Conference was conducted on 08/09/2024 with the Administrator, the Alternate Administrator/Alternate Supervising Nurse, the Supervising Nurse, the Licensed Vocational Nurse/Biller, and the Clerk at 12:30 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: L&CHHS - Licensed and Certified 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 2 of 168 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 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 2 assessments and the percentage of assessments with this error was 1.19% of assessments completed by the Agency. An interview was conducted with the Supervising Nurse on 08/09/2024 at 10:12 AM. The "HHA Error Summary by Agency" report was reviewed for the time-period of 05/12/2023 to 12/31/2023. The Alternate Administrator stated the Licensed Vocational Nurse/Biller is responsible for electronically transmitting OASIS. An interview was conducted with the Licensed Vocational Nurse/Biller on 08/09/2024 at 10:18 AM. The Licensed Vocational Nurse/Biller stated she had identified the cause of the late submission for the two clients (Clients #1 and #2) listed on the “HHA Error Summary Report.” The Licensed Vocational Nurse/Biller stated the cause for the late submission for Client #1 was due to the nurse who completed the assessment signing the assessment late, although the assessment was documented timely. The Licensed Vocational Nurse/Biller stated the cause for the late submission for Client #2 was due to a clerical error. During the exit conference on 08/09/2024 at 12:30 PM, the findings were presented to the Administrator and the Alternate Administrator/Alternate Supervising Nurse. No additional information was provided. Review of the Agency’s policy and procedure manual revealed a policy titled, “OASIS Collecting, Encoding, and Transmitting,” dated 06/12/2020, which read in part, “The Agency must encode and electronically 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.”