Every finding on record at Breeze Home Healthcare LLC

A recertification survey entrance conference was conducted on 09/30/2024. The census was - 16 Licensed and Certified patients – 16 Licensed Home Health patients - 0 Personal Assistance Services patients -0 The agency met Medicare Conditions of Participation for Emergency Preparedness.

A recertification survey entrance conference was conducted on 09/30/2024. The census was – 16 Licensed and Certified patients – 16 Licensed Home Health patients - 0 Personal Assistance Services patients -0 The agency met Medicare Conditions of Participation with standard level deficiency. Abbreviations: ADM – Administrator CMS - Centers for Medicare & Medicaid Services DON - Director of Nurses Alt DON – Alternate Director of Nurses HHA – Home Health Agency IQIES - IQIES - Internet Quality Improvement and Evaluation System 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 electronically transmit completed OASIS (a standardized data set that measures the quality and outcomes of home health patients) assessments to the CMS system for all Medicare patients within 30 days of completing the OASIS assessment of the beneficiary (patients) for 16.99% (39 of 230) of assessments transmitted during 10/02/2023 – 10/02/2024. This failure prevented the agency’s patient data from being made available to CMS within 30 days of the OASIS completion dates for analysis to identify agency performance levels in the provision of patient care. Findings included: During pre-survey activity on 09/30/2024: The surveyor reviewed the agency OASIS report titled, “HHA Error Summary by Agency” from IQIES (an internet-based system that includes survey and certification functions) during the one-year of 10/01/23 – 9/30/24. The HHA Error Summary by Agency report included 39 of 230 OASIS assessments (16.99%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment. An interview was conducted with the ADM on 09/30/2024 at 11:40 PM. The ADM stated the DON and Alt DON were responsible for OASIS assessment submission to the CMS system. An interview was conducted with the ADM and Alt DON on 10/03/2024 at 2 PM and the surveyor reviewed the error summary report which included 39 OASIS assessments submitted late. The Alt DON stated some OASIS assessments had been submitted close to the submission date and she did not realize they were submitted late, which resulted in the agency not following its policy. Agency Policy titled, "Timelines IM.35" with a revision date of 05/02/2024, read in part, “…Purpose To establish timely parameters for all medical record information… Procedure… II. All completed and encoded OASIS data will be transmitted… to the CMS collection site within 30 days of the M0090 date…”

Purpose of Visit: Recertification Survey Entrance Date: 09/13/21 Census: L&C - 24 LHH - 0 PAS - 0 The Breeze Home Healthcare LLC home health agency is in compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies.

Purpose of Visit: Recertification Survey and a Follow-Up to the Survey Conducted on 04/10/18 Entrance Date: 09/13/21 Census: L&C - 24 LHH - 0 PAS - 0 Acronyms/Definitions: 1.) OASIS - Outcome and Assessment Information Set 2.) RN - Registered Nurse 3.) PT - Physical Therapist 4.) OT - Occupational Therapist 5.) ST - Speech Therapist 6.) Osteoarthritis - a medical condition which results in degeneration of the cartilage of the joints and underlying bone causing pain and stiffness. 7.) COPD - Chronic Obstructive Pulmonary Disease - a medical condition which causes obstructed air flow from the lungs resulting in difficulty breathing. 8.) HTN - Hypertension - High Blood Pressure 9.) Dementia - a medical condition which includes a decline in cognitive ability including memory, judgement, and decision-making ability over time. 10.) D/C - Discharge 11.) pt./Pt. - Patient

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to update and revise the comprehensive assessment, including the administration of the OASIS assessment, as frequently as the patient's condition requires but not less frequently than at discharge for 2 of 2 (Patient #6 and Patient #7) discharged patients reviewed. This failure resulted in the agency having incomplete assessment information regarding the patient's condition at the time of discharge. The findings included: Record review of the agency's policy and procedure manual indicated the agency had adopted a policy titled, "Patient/Client Transfer/Discharge and Agency Dissolution," dated 08/01/20, which indicated, "The Discharge Assessment will be completed within forty-eight (48) hours of knowledge of the discharge. The OASIS discharge assessment, as appropriate, will be completed by the last discipline in the home ... In the event the discharge is not planned, the OASIS data is based on the last assessment by the RN, PT, OT, or ST." Record review of the clinical record for Patient #6 included a plan of care, for the certification period of 02/04/21 - 04/04/21, which indicated the patient had a start of care date of 08/08/20. The plan of care indicated the patient had diagnoses of osteoarthritis, COPD, hypertension, and dementia. The plan of care indicated the patient was to receive skilled nursing visits once a week for eight weeks. Record review of the clinical record for Patient #6 included a physician's order, dated 02/19/21, which indicated, "D/C pt. on 2/19/21." Record review of the clinical record for Patient #6 did not include documentation of a comprehensive assessment, including the administration of the OASIS assessment, which was completed at the time of the patient's discharge from the agency. Record review of the clinical record for Patient #7 included a plan of care, for the certification period of 05/04/21 - 07/02/21, which indicated the patient had a start of care date of 03/05/21. The plan of care indicated the patient had diagnoses of osteoarthritis, hypertension, and COPD. The plan of care indicated the patient was to receive skilled nursing visits once a week for eight weeks. Record review of the clinical record for Patient #7 included a physician's order, dated 05/31/21, which indicated, "D/C Pt. on 5/31/21." Record review of the clinical record for Patient #7 did not include documentation of a comprehensive assessment, including the administration of the OASIS assessment, which was completed at the time of the patient's discharge from the agency. During an interview conducted on 09/14/21 at 12:00 p.m., the administrator said the agency's consultant told them they no longer needed to complete a discharge assessment, including the OASIS assessment, for patients if they do not have a visit with the patient on the date of the discharge. During an interview conducted on 09/14/21 at 1:33 p.m., the administrator said the discharge assessment, including the OASIS assessment, was not completed for Patient #6 or Patient #7 because the agency's consultant told them they did not need to complete the discharge assessment, including the OASIS assessment, if the patient declined the discharge visit or further services from the agency. During an interview conducted on 09/14/21 at 5:11 p.m., with the administrator, the alternate administrator, and the alternate supervising nurse, when presented with the findings documented above, the alternate supervising nurse said the agency had not completed discharge assessments, including the OASIS assessments, for the last two years since their consultant told them they did not need to do these.