Every finding on record at Better Living Home Health Agency Inc

During the Recertification survey conducted on 3/4/25-3/6/25 at Better Living Home Health Agency Inc, a Home Health Agency, Emergency Preparedness was reviewed. Better Living Home Health Agency Inc is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.102, Condition of Participation for Home Health Agencies.

A recertification survey was completed on 3/4/25 to 3/6/25 at Better Living Home Health Agency Inc. The facility was not in compliance with Code of Federal Regulations (CFR) 42, Part 484, Condition of Participation for Home Health Agencies.

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 staff interview, medical record review, and agency policy review, it was determined that the agency failed to ensure they electronically transmitted each completed Outcome and Assessment Information Set (OASIS) assessment to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of completing the assessment of the patient for three patients out of seven patients reviewed. The findings include: During survey preparation, it was revealed the agency had a year to date (1/1/25- 3/3/25) -3330 error rate of 38.64%, which showed 17 OASIS assessments out of 44 OASIS assessments completed in that time frame were not transmitted to CMS within 30 days of the assessment being completed. During medical record review, it was revealed three out of seven medical records reviewed (Patient #2, Patient #3, and Patient #4) did not have an OASIS assessment transmitted to CMS within 30 days of the assessment being completed: Patient #2: OASIS assessment for Resumption of Care completed on 12/31/24; transmitted to CMS on 2/24/25. Patient #3: OASIS assessment for Start of Care completed on 1/10/25; transmitted to CMS on 2/24/25. Patient #4: OASIS assessment for Discharge completed on:1/19/24; transmitted to CMS on 2/13/25. During an interview with the Administrator on 3/5/25 at 2:30pm, she was asked who is responsible for transmitting the OASIS assessments to CMS. She stated she is. She was asked when the OASIS assessments should be transmitted to CMS. She stated within 30 days. She was asked if she was aware of the agency's high year to date error rate for transmitting OASIS assessments to CMS. She stated, "We used to track it when we had more staff, but now being smaller, we haven't been tracking it so much." She was asked if she could confirm if Patient #2, Patient #3, and Patient #4 had OASIS assessments that were not transmitted to CMS within 30 days. She stated Yes, that is true. A review of the agency policy titled "Timely Submission of Patient Documentation" (undated) revealed: Policy: The agency will ensure timely and proper submission of patient documentation. Purpose: To comply with state/federal laws and regulations related to timely submission of all patient documentation. A review of the agency policy titled "OASIS Assessment and Compliance" (undated) revealed: Policy: All adults for skilled services by the agency shall have the appropriate OASIS forms completed within the designated time frames. All agency staff shall comply with all requirements for OASIS assessment and transmission.