Every finding on record at Calvary Health Care Inc

A recertification survey was initiated on 2/8/2024. The census was: LCHH-94 LHH-0 PAS-88 Total agency census: 182 Intake 483572 Abbreviations: LCHH-Licensed and Certified Home Health LHH-Licensed Home Health PAS-Personal Assistant Services The agency was in compliance with 42 CFR part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A recertification survey was initiated on 2/8/2024. The census was: LCHH-94 LHH-0 PAS-88 Total agency census: 182 Intake 483572 Abbreviations: LCHH-Licensed and Certified Home Health LHH-Licensed Home Health PAS-Personal Assistant Services OASIS-Outcome and Assessment Information Set iQies-Internet Quality Improvement 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 and interview, the agency failed to transmit completed OASIS assessments to the State agency within 30 days of completing the OASIS assessment of the beneficiary (patient) for 31.34% of the assessments transmitted during the 3 month period of 10/1/23 to 12/31/23. Failure of the agency to transmit OASIS data within the required time frame prevented the agency's patient data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. Findings include: On 2/15/24 at 9:30 am, the surveyor asked Employee A, Administrator for the OASIS error summary report from October 1, 2023 through December 31, 2023. The error summary report read in part…”Error -3330, record submitted late: The submission date is more than 30 days after M0090. # (number) of assessments processed, 201.”… 63, 31.34% submitted over 30 days after the M0090 date. In an interview on 2/15/24 at 9:55 am, the surveyor reviewed the iQies error summary report by agency from October 1, 2023 through December 31, 2023 with the Administrator and the Administrative Assistant. The surveyor explained that 31% of OASIS were being submitted late. The Administrator said, " I don’t know why, but I will work on that moving forward.” The surveyor asked the Administrator who was responsible for submitting the OASIS. The Administrator said, “The Administrative Assistant.” The surveyor asked if the Administrative Assistant knew why the submissions were late. The Administrative Assistant said, “No ma’am, I don’t, because I submit the first and fifteenth every month.” Agency policy, “8.10 Timelines” revised 1/29/20 read in part…”The Agency will ensure timely provision of service and services to meet the client’s needs in compliance with all federal and state laws and regulations…Completed, encoded and locked OASIS date will be transmitted within thirty (30) days of the M0090 date.”…

An entrance conference was conducted with the Alternate Administrator on 01/28/21 at approximately 10:30 am. The Administrator was informed that the purpose of the survey was to conduct an Recertification Survey. What To Expect During Your Agency's Survey" was provided and explained. Written information was provided with instructions on how to complete the on-line "Comment Card Survey" was provided. Agency census: Licensed and Certified Home Health-105 Licensed Home Health-0 Personal Assistance Services: 80 Total agency census-185 An exit conference was conducted with the Alternate Administrator on 02/02/21 at approximately 3:15 pm . The preliminary findings of the survey were discussed and a written copy provided. The agency was informed there were of the records duplicated. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions were provided and explained for submitting an acceptable plan of correction within 10 days of receipt of the Statement of Violations. The agency was informed that violations would be cited. SN-skilled nurse RN - registered nurse LVN - licensed vocational nurse PT - physical therapist OT - occupational therapist POC/485 - plan of care SOC - start of care NOMNC - Notice of Medicare Non-Coverage QIO - Quality Improvement Organization CoP's - Conditions of Participation BNI - Benefits Improvement and Protection Act CMS - Center for Medicare and Medicaid PAS - Personal Assistance Services

An entrance conference was conducted with the Alternate Administrator on 01/28/21 at approximately 10:30 am. The Administrator was informed that the purpose of the survey was to conduct an Recertification Survey. What To Expect During Your Agency's Survey" was provided and explained. Written information was provided with instructions on how to complete the on-line "Comment Card Survey" was provided. Agency census: Licensed and Certified Home Health-105 Licensed Home Health-0 Personal Assistance Services: 80 Total agency census-185 An exit conference was conducted with the Alternate Administrator on 02/02/21 at approximately 3:15 pm . The preliminary findings of the survey were discussed and a written copy provided. The agency was informed there were of the records duplicated. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions were provided and explained for submitting an acceptable plan of correction within 10 days of receipt of the Statement of Violations. The agency was informed that violations would be cited. SN-skilled nurse RN - registered nurse LVN - licensed vocational nurse PT - physical therapist OT - occupational therapist POC/485 - plan of care SOC - start of care NOMNC - Notice of Medicare Non-Coverage QIO - Quality Improvement Organization CoP's - Conditions of Participation BNI - Benefits Improvement and Protection Act CMS - Center for Medicare and Medicaid PAS - Personal Assistance Services

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review of agency documents and interviews, the agency failed to provide the correct name of the current QIO, in accordance with the Centers for Medicare and Medicaid in 3 (Patients 11, 12, and 13) of 3 discharged patients whose records were reviewed, in that: the agency failed to include the name, address, or telephone number of the QIO on the NOMNC form The failure could place the agency patients at risk of harm if the NOMNC form is not provided with accurate information for the current QIO, in the event such information was needed by the Patients at discharge. Findings included: Patient #11: Review of the discharged clinical record was completed on 02/02/21. Patient #11 was discharged on 05/20/21. The NOMNCdischarge document, contained in the clinical record, revealed that no QIO was listed for the patient to utilize to file an appeal. Review of the NOMNC document revealed the NOMNC read in part "HOW TO ASK FOR AN IMMEDIATE APPEAL"... "Call your QIO at: {insert name and number of QIO} to appeal." As a result, the patient had no access to the current QIO because the agency failed to list the current QIO information: (IE) (name/address/telephone number), as one of the entities required to be listed by the January 2018 Federal CoPs. Patient #12: Review of the discharged clinical record was completed on 02/02/21. Patient #12 was discharged on 10/30/20. The NOMNC (discharge document), contained in the clinical record, revealed that no QIO was listed for the patient to utilize to file an appeal. Review of the NOMNC document revealed the NOMNC read in part "HOW TO ASK FOR AN IMMEDIATE APPEAL"... "Call your QIO at: {insert name and number of QIO to appeal." As a result, the patient had no access to the current QIO because the agency failed to list the current QIO information: (IE) (name/address/telephone number), as one of the entities required to be listed by the January 2018 Federal CoPs. Patient #13: Review of the discharged clinical record was completed on 02/02/21. Patient #13 was discharged on 06/05/21. The NOMNC discharge document, contained in the clinical record, revealed that no QIO was listed for the patient to utilize to file an appeal. Review of the NOMNC document revealed the NOMNC read in part "HOW TO ASK FOR AN IMMEDIATE APPEAL"... "Call your QIO at: {insert name and number of QIO} to appeal." As a result, the patient had no access to the current QIO because the agency failed to list the current QIO information: (IE) (name/address/telephone number), as one of the entities required to be listed by the January 2018 Federal CoPs. During an interview with Employee A, Alternate Administrator 02/04/21 at approximately 2:30 pm. the surveyor discussed the above findings and asked the Administrator if he knew why the information on the agency NOMNC discharge form failed to list the correct QIO. The Alternate Administrator said, "No ma'am." The surveyor explained that the patients would be unable to appeal the discharge if not provided with the QIO information."