Every finding on record at Bayside Home Health Care Inc

Purpose of Survey – To conduct recertification/relicensure survey On 02/04/25 at 1:40 p.m., the surveyor conducted an unannounced visit and an entrance conference with the Alt Adm/DON. Census- L&CHHS – 10 LHH – 0 An exit conference was conducted on 02/07/24 at 04:30 p.m., with the Adm and Alt Adm/DON. Abbreviations: Adm – Administrator Alternate Adm – Alternate Administrator DON – Director of Nurses ERP – Emergency Preparedness and Response Plan L&CHHS – Licensed and Certified Home Health Services LHH – Licensed Home Health

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on record review and interview, the Agency written emergency preparedness and response plan (ERP) failed to include a continuity of operations business plan that addressed essential functions for patient services, critical personnel and how to return to normal operations as quickly as possible. This failure could place the Agency’s active clients at risk of harm from employees that are unfamiliar with their job responsibilities during a natural or man-made disaster or emergency. The findings included: Record review of the Agency’s emergency preparedness and response binder included a completed “Ready Business, Business Emergency Plan… Business Continuity and Disaster Preparedness Plan” dated 12/20/24, 12/18/23 and 12/21/22 that addressed Agency’s “Plan to stay in Business”. Record review of the Agency’s “Business Emergency Plan” dated 12/20/24, 12/18/23 and 12/21/22 failed to document the actions and responsibilities of Agency staff in each phase of emergency planning, including mitigation, preparedness, response, and recovery. In a simultaneous record review of the Agency’s “Emergency Preparedness and Response Plan” binder and interview on 02/07/25 at 03:20 p.m., the Alt Adm/DON identified herself as the Alt Disaster Coordinator. The Alt Adm/DON stated the Agency held Emergency Preparedness meetings two times per year held simultaneously “during the quality assurance and performance improvement (QAPI) meetings”. The Alt Adm/DON identified the “Ready Business, Business Emergency Plan…Business Continuity and Disaster Preparedness Plan” as the Agency’s emergency preparedness and response plan. The Alt Adm/DON stated the ERP did not document how the actions and responsibilities of each staff member during each phase of emergency planning. The Alt Adm/DON stated she did not know why it was not documented. The Alt Adm/DON stated the information was documented in the Agency’s policy, but it was not “spelled out” in the Agency’s plan “doing each thing”. In an interview on 02/07/25 at 03:50 p.m., the Adm identified himself as the Disaster Coordinator and stated he was responsible for designating the Agency staff’s responsibilities. The Adm stated the Agency was “proactive and prepared for hurricanes”. The Adm stated the Agency would start “calling patients” as soon as the Agency activated their emergency preparedness plan. The Adm stated staff all had cell phones they used to communicate and they “worked remotely”. They Adm stated the Agency did not have a “huge census” and did not have a lot of clients or staff to contact. The Adm stated they ‘had worked for over 20 years”, had reviewed the emergency preparedness plan and the plan did document the actions and responsibilities of Agency staff in each phase of emergency planning. Record review of the Agency’s policies titled, “Emergency Preparedness Policy and Plan”, with a revised date of 12/10/18, quoted in part, “Agency will develop a Business Continuity and Disaster Preparedness Plan to ensure needs of agency, staff and patients are met…(5) Agency leaders will develop the Business Continuity and Disaster Preparedness Plan which will be maintained in the Emergency Preparedness and Response Plan Manual to address…Essential functions for patients services…critical personnel, roles, and responsibilities…

Purpose of Survey – To conduct recertification survey On 02/04/25 at 1:40 p.m., the surveyor conducted an unannounced visit and an entrance conference with the Alt Adm/DON. Census- L&CHHS – 10 LHH -0 An exit conference was conducted on 02/07/24 at 04:30 p.m., with the Adm and Alt Adm/DON. The preliminary findings were discussed. The agency was given the opportunity to provide additional information. Abbreviations: Adm – Administrator Alt Adm – Alternate Administrator CMS – Centers for Medicare and Medicaid DON – Director of Nurses L&CHHS – Licensed and Certified Home Health Services LHH – Licensed Home Health OASIS – Outcome and Assessment Information Set

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 transmit completed OASIS (Outcome and Assessment Information Set) Assessments within 30 days of completions for 68 of 126 assessments submitted between 03/25/24 through 01/29/25. This failure prevented the patient’s data from being made available to the Center’s for Medicare and Medicaid (CMS) for analysis to identify Agency performance levels in the provision of patient care. Findings included: Record review of the IQIES “Home Health Error by Summary Agency” report generated from the CMS national data system during presurvey preparation on 02/03/25 revealed the Agency had submitted and processed 72 assessments. The report indicated the Agency had a 51.06% of assessments with -3330 error that indicated the assessments were submitted after the 30th date of the M0090 date. Record review of the Agency OASIS final validation reports dated 03/25/24 through 01/29/25 revealed 126 total assessments were processed by the agency. Further review of the Agency OASIS final validation reports revealed 68 of the 126 assessments had error -3330 indicating those records were submitted after the 30th date of the M0090 date. In an interview on 02/07/25 at 02:10 p.m., the Alt Adm/DON s the Agency’s policy for submitting OASIS assessments was no later than 5 days after the client’s start of care. The Alt Adm/DON stated she was not aware the Agency was having difficulties submitting the assessments on time and or that it was a problem. The Alt Adm/DON stated Staff C was responsible for submitting all OASIS assessments for the Agency. Alt Adm/DON stated the assessments were being completed and signed within 24 hours and submitted. The Alt Adm stated she was not sure what the problem with submitting the assessments to CMS was. The Alt Adm/DON stated, “maybe we [the Agency] need to review the systems [electronic medical record systems]” The Alt Adm stated she could not complete the assessment because unless it was locked and “maybe the problem was with the Agency’s electronic medical records”. The Alt Adm/DON stated the assessment was not showing “locked” status on the biller side, but it was showing “locked” status on the nurse’s side. The Alt Adm/DON stated the electronic medical record would not let the nurse complete or close the assessment out. The Alt Adm/DON stated this problem should have been communicated to her by her staff. In an interview on 02/07/25 at 02:15 p.m., Staff C stated he submitted the assessments to CMS as soon as the nurses had them locked and ready to go to OASIS and bill. Staff C stated he had not had any issues unless something got rejected. Staff C stated there were times when he was aware the assessments were late and that he and the Agency clerk would discuss them but did not notify the Alt Adm/DON. Staff C stated he “assumed” the Agency clerk would notify the Alt Adm/DON regarding the late submission. In an interview on 02/07/25, at 02:25 p.m., the Adm stated submissions of the OASIS assessments to CMS was part of the clinical responsibility of the nurses and he had “no involvement” in those duties. The Adm stated he was not aware there was a problem regarding submission of the OASIS assessments to CMS. Record review of Agency policies titled “IM.10 Timelines”, with a revised date 01/13/18, quoted in part, “Agency will ensure timely provision of care and services to mee the patient’s needs in compliance with all federal and state laws and regulations and standards of practice…Encoding and transmission of OASIS data to CMS (centers for Medicare and Medicaid) is performed at least monthly and prior to billing. The OASIs is required to be transmitted to CMS within 30 days of date of the assessment is completed (M0090) …” Record review of Agency policies titled “IM.11 OASIS Collecting, Encoding and Transmitting” with a revised date 01/13/18, quoted in part, “C. §484.45(a) Encoding and transmitting OASIS data…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…”