Every finding on record at Chippewa County Montevideo Hospital Home Care

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 1/7/25 to 1/8/25, during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 1/7/25-1/8/25, a recertification survey was conducted. This resulted in a partial extended survey at CCM Home Care. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. Unduplicated census previous 12 months: 203 Total home visits conducted: 3 Parent location: 1409 MN-7, Montevideo, MN 56265 Hours of Operation: 8-4:30 pm List total number of records reviewed: 7

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 document review, the facility failed to report all OASIS data collected in accordance with federal regulations. The total number of records submitted beyond the 30 days was 32. Findings include: On the OASIS Error Detail Report period from 1/1/25 to 12/31/25, the agency had an error code of -3330: record submitted late. The description included the submissions were more than 30 days after completion on the new record. Further review of the OASIS Error Detail Report period from 1/1/25 to 12/31/25, the agency had 27 late submissions with a submission date of 9/12/25, and five additional late submissions dated 1/23/25, 2/24/25, 12/9/25, 12/16/25, and 12/31/25. During an interview on 1/8/25 at 11:00 a.m., clinical manager (CM)-A stated the agency's normal OASIS assessment process was to submit the assessments weekly on Wednesday. CM-A stated she was made aware via email from health information system on 9/4/25, that OASIS reports were not submitting correctly through their electronic health record (EHR) system, and affected assessments would be resubmitted. CM-A stated she was not aware of the number of assessments affected and knew the problem had been corrected by the EHR company. CM-A stated the other late submissions were due to needing to change the assessment type from transfer without discharge assessment to transfer with discharge assessment. Agency Comprehensive Client Assessment policy revised 11/2023, indicated OASIS data elements will be included in the assessment of all clients receiving skilled services and are covered by Medicare, Medicaid, VA payer sources. The policy did not mention timely submission of OASIS data.