Every finding on record at Calura Home Health Services Inc

During an unannounced recertification survey conducted on 3/18-19/25 at Calura Home Health Services, Inc, Emergency Preparedness was reviewed. The Home Health Agency was in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

An unannounced recertification survey was conducted at Calura Home Health Services, Inc on 3/18/25 - 3/19/25. At the time of the survey, the home health agency was not in compliance with Code of Federal Regulations (CFR) 42, Part 484.22, 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 interviews, and record reviews, the agency failed to ensure they encoded and electronically transmitted a completed OASIS (Outcome and Assessment Information Set) assessment to CMS (Centers for Medicare and Medicaid Services) system within 30 days of completing the assessment for 5 of 8 patients sampled (patients #1, 5, 6, 8, and 9). The findings include: A review of the iQIES Home Health Summary by Agency Report for error code -3330 (OASIS data submission of greater than 30 days from the M0090 date) revealed the home health agency had an error rate of 78.72% for the last year (2023-2024) and a year-to-date error rate of 72.73%. A review of the record for patient #1 revealed his comprehensive assessment was completed on 1/14/25 and the OASIS data was not submitted until 3/05/25. Review of the submission report revealed an error message “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record”. A review of the record for patient #5 revealed her comprehensive assessment was completed on 10/03/24 and the OASIS data was not submitted until 11/07/24. Review of the submission report revealed an error message “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record”. Further review of the record revealed the patient was readmitted to the agency on 1/08/25 and the OASIS data was not submitted until 3/05/25. A review of the record for patient #6 revealed his comprehensive assessment was completed on 11/05/24 and the OASIS data was not submitted until 12/10/24. Review of the submission report revealed an error message “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record”. Further review of the record revealed the patient was readmitted to the agency on 1/14/25 and the OASIS data was not submitted until 3/05/25. A review of the record for patient #8 revealed his comprehensive assessment was completed on 1/16/25 and the OASIS data was not submitted until 3/05/25. Review of the submission report revealed an error message “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record”. A review of the record for patient #9 revealed his comprehensive assessment was completed on 10/02/24 and the OASIS data was not submitted until 11/07/24. Review of the submission report revealed an error message “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record”. On 3/19/25 at approximately 12:00 PM an interview was conducted with staff member A, Licensed Practical Nurse/Quality Assurance, during which she stated that the agency was aware of the ongoing issues with OASIS submissions. She verified the late submissions, and the agency’s high -3330 error rate stating that it was so high because they have so few patients. She verified that of the 8 OASISs reviewed 5 were late. She stated this was their fault and that they are now checking them daily.