Every finding on record at Cloudview Home Health Agency Inc

An Entrance Conference was conducted on 07/09/2024 with the Administrator at 1:40 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 - 62 An Exit Conference was conducted on 07/11/2024 with the Administrator, the Alternate Administrator, the Human Resources Clerk, the Quality Assurance Coordinator, the Medical Records Coordinator and via telephone with the Supervising Nurse at 5:00 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 CMS - Centers for Medicare & Medicaid Services OASIS - Outcome and Assessment Information Set iQIES - Internet Quality Improvement and Evaluation System HHA - Home Health Agency

An Entrance Conference was conducted on 07/09/2024 with the Administrator at 1:40 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 - 62 An Exit Conference was conducted on 07/11/2024 with the Administrator, the Alternate Administrator, the Human Resources Clerk, the Quality Assurance Coordinator, the Medical Records Coordinator and via telephone with the Supervising Nurse at 5:00 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 CMS - Centers for Medicare & Medicaid Services OASIS - Outcome and Assessment Information Set iQIES - Internet Quality Improvement and Evaluation System HHA - Home Health Agency

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 5 of 357 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 5 assessments and the percentage of assessments with this error was 1.40% of assessments completed by the Agency. An interview was conducted with the Administrator and the Supervising Nurse on 07/11/2024 at 12:40 PM. The HHA Error Summary Report for the time-period of 05/12/2023 to 12/31/2023 was reviewed with the Administrator and the Supervising Nurse. The Administrator stated herself, the Biller and the Supervising Nurse all monitor to ensure OASIS assessments are submitted in a timely manner. The Administrator stated they would look into this. On 07/11/2024, at 2:50 PM, an additional interview was conducted with the Administrator and the Supervising Nurse. The Administrator stated they were able to locate OASIS Agency Final Validation reports which revealed 3 of the 5 assessments that were not transmitted within the required timeframe were due to the assessment initially transmitted in a timely manner but then rejected for reasons such as an incorrect Medicare beneficiary identifier number. The Administrator stated by the time the assessment was rejected, corrected, and transmitted again, it was being recognized as being transmitted after the required time-frame. Documentation provided by the Administrator revealed a policy titled “OASIS Compliance,” dated 4Q(quarter)/2022 which read in part, “Within 30 days of assessment completion (OASIS item M0090), OASIS data elements will be encoded and electronically transmitted to the national OASIS system.”