Every finding on record at Cedar Lake Nursing Services Inc

A Recertification survey was conducted on 10/9/24 at 2:00 pm. The census was 242. Trinidad office (Parent): Licensed and certified – 48 Licensed Home Health – 126 Personal Assistive Services - 0 Corsicana branch: Licensed and Certified – 5 Licensed Home Health – 63 Personal Assistive Services – 0 There were no deficiencies related to Emergency Preparedness.

A Recertification survey was conducted on 10/9/24 at 2:00 pm. The census was 242. Trinidad office (Parent): Licensed and certified – 48 Licensed Home Health – 126 Personal Assistive Services - 0 Corsicana branch: Licensed and Certified – 5 Licensed Home Health – 63 Personal Assistive Services - 0 Abbreviations included: OASIS – Outcome and Assessment Information Set QAPI- Quality Assessment Performance Improvement iQies – Internet Quality Improvement and Evaluation System CMS – Centers for Medicare and Medicaid Services

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 interview and record review, the agency failed to code and electronically transmit each completed OASIS (data collected as part of the comprehensive assessment) assessment to the CMS system within thirty days of completing the assessment of the beneficiary for 82 of 2633 records submitted (3.11%). The agency did not code and electronically submit patient’s OASIS data to IQIES (electronic system used to transmit quality measures from the OASIS data collected during comprehensive assessments) within 30 days to track and evaluate changes in the patient’s health while admitted to home health services to help ensure quality healthcare for patients. This failure prevented the agency’s patient OASIS data from being made available to CMS for analysis of patient care performance. Review of an IQIES Error Summary Report dated 10/7/23 to 10/7/24 generated by the surveyor during pre-survey indicated the agency failed to code and electronically transmit 82 of 2633 OASIS assessments data to the CMS system within thirty days of completing the assessment of the beneficiary. During an interview on 10/8/24 at 1:05 p.m., the Alternate Administrator/Supervising Nurse said she was responsible for submitting the OASIS assessments. The Alternate Administrator/Supervising Nurse said the assessments were to be transmitted within 30 days of completion. She said she was aware that some assessments had been submitted late but was surprised to learn that 82 assessments were late in the last 12 months. Record Review of an agency policy titled Timelines, revised 08/01/20, indicated all completed and encoded OASIS data will be transmitted within 30 days of the M0090 (the date the assessment is actually completed) date.