Every finding on record at Balm in Gilead Home Health Services Inc

A recertification survey entrance conference was conducted on 10/08/2024. The census was 3. L&C: 3 LHH:0 PAS: 0 The agency was in substantial compliance with 42 CFR Part 484.22, emergency preparedness requirement for home health agencies.

A recertification survey entrance conference was conducted on 10/08/2024. The census was 3. L&C: 3 LHH: 0 PAS:0 Acronyms used: L&C- licensed and certified LHH- licensed home health PAS- personal assistant services OASIS- Outcome and Assessment Information Set CMS- Centers for Medicare and Medicaid Services DON- Director of nurses IQIES- Internet Quality Improvement and Evaluation System

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, interview and observation, 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 2 of 29 assessments submitted. 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 generated by the surveyor indicated the agency failed to code and electronically transmit 2 OASIS assessments data to the CMS system within thirty days of completing the assessment of the beneficiary. During an interview on 10/8/2024 at 1:23 p.m., the alternate administrator said the administrator was responsible for the agencies OASIS submissions. During an interview on 10/10/2024 at 10:34 a.m., the administrator said he was responsible for the agencies OASIS submissions. The administrator said the DON/alternate administrator would tell him when the assessments were completed and ready for submission. The administrator said there may have been some miscommunication between him and the DON when something was ready to be submitted which caused the late submissions. The administrator said the agency had 30 days to submit the OASIS. The administrator said it was important to submit OASIS timely because it was regulation. Record review of a policy dated 05/02/24 titled Timelines indicated all completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data entry, and that includes the required OASIS data set and the CMS-assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with the federal information processing standard from the agency or the agency contractor to the CMS collection site within 30 days of the M0090 date.