Every finding on record at Canine Friendly Coalition Inc

An Entrance Conference was conducted on 07/23/2024 with the Administrator and the Supervising Nurse at 1:50 PM. The Agency representatives were informed the purpose of the survey was a Recertification Survey. Written information regarding "What to Expect During Your Agency's Survey" was provided. The Agency census was: L&CHHS - 90 PAS - 0 An Exit Conference was conducted on 07/26/2024 with the Alternate Administrator, the Office Manager and the Supervising Nurse at 1:45 PM. The Agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations/Acronyms/Definitions: L&CHHS - Licensed and Certified Home Health Services PAS - Personal Assistance Services CMS - Centers for Medicare & Medicaid Services OASIS - Outcome and Assessment Information Set iQIES - Internet Quality Improvement and Evaluation System HHA - Home Health Agency QAPI - Quality Assessment Performance Improvement

An Entrance Conference was conducted on 07/23/2024 with the Administrator and the Supervising Nurse at 1:50 PM. The Agency representatives were informed the purpose of the survey was a Recertification Survey. Written information regarding "What to Expect During Your Agency's Survey" was provided. The Agency census was: L&CHHS - 90 PAS - 0 An Exit Conference was conducted on 07/26/2024 with the Alternate Administrator, the Office Manager and the Supervising Nurse at 1:45 PM. The Agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations/Acronyms/Definitions: L&CHHS - Licensed and Certified Home Health Services PAS - Personal Assistance Services CMS - Centers for Medicare & Medicaid Services OASIS - Outcome and Assessment Information Set iQIES - Internet Quality Improvement and Evaluation System HHA - Home Health Agency QAPI - Quality Assessment Performance Improvement

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 encode and electronically transmit each completed OASIS (A tool used by CMS to collect certain patient information) assessment to the CMS system, within 30 days of completing the assessment of the patient for 35 of 809 assessments processed for the time-period reviewed of 05/12/2023 to 12/31/2023. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare and patient care failing to be reported to CMS in the required time-frame. Findings Included: The HHA Error Summary Report, retrieved from the iQIES website for the time-period of 05/12/2023 to 12/31/2023 was reviewed. Review of the HHA Error Summary Report for the time-period of 05/12/2023 to 12/31/2023 identified Error #-3330. The description for Error #-3330 read in part, “Record Submitted Late: The submission date is more than 30 days after M0090 (Item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with this error was 35 assessments and the percentage of assessments with this error was 4.33% of assessments completed by the Agency. Review of the Agency's QAPI Plan and Committee Meeting Minutes for the time-period reviewed of 2021, 2022 and 2023 revealed the Agency had been monitoring OASIS data during each QAPI meeting. An interview was conducted with the Administrator, the Alternate Administrator, and the Office Manager on 07/26/2024 at 12:55 PM. The "HHA Error Summary by Agency" report was reviewed for the time-period of 05/12/2023 to 12/31/2023. The Alternate Administrator stated the Office Manager was responsible for monitoring OASIS data. The Office Manager confirmed she believed the issue may be caused due to OASIS assessments being submitted within the required time frame, however rejected due to an error and the when the assessment was corrected and submitted, the assessment reflected as late. The Office Manager stated that she tracks the submission of OASIS assessments and has documentation of OASIS Final Validation Reports for the year of 2023. The Office Manager stated that she would review this documentation to determine what caused the late submission of OASIS assessments.