Every finding on record at Cuidado Casero Home Health of El Paso Inc

An Entrance Conference was conducted on 09/10/2024 with the Alternate Administrator/Supervising Nurse, the Director of Medicaid Programs, and via telephone with the Administrator/Alternate Supervising Nurse at 1:55 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 – 27 LHHS - 52 PAS – 179 An Exit Conference was conducted on 09/12/2024 with the Alternate Administrator/Supervising Nurse, the Director of Medicaid Programs, and via telephone with the Administrator/Alternate Supervising Nurse at 4:40 PM. The preliminary findings of the survey were discussed. The Agency is in substantial compliance with Conditions of Participation for Emergency Preparedness. Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services LHHS – Licensed Home Health Services PAS - Personal Assistance Services

An Entrance Conference was conducted on 09/10/2024 with the Alternate Administrator/Supervising Nurse, the Director of Medicaid Programs, and via telephone with the Administrator/Alternate Supervising Nurse at 1:55 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 – 27 LHHS - 52 PAS – 179 An Exit Conference was conducted on 09/12/2024 with the Alternate Administrator/Supervising Nurse, the Director of Medicaid Programs, and via telephone with the Administrator/Alternate Supervising Nurse at 4:40 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: L&CHHS - Licensed and Certified Home Health Services LHHS – Licensed 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

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 431 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 1.16% of assessments completed by the Agency. An interview was conducted with the Alternate Administrator/Supervising Nurse on 09/12/2024 at 1:35 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/Supervising Nurse stated timeliness of completion of documentation of the OASIS assessment and failure to monitor OASIS validation reports are factors that potentially resulted in late submissions of OASIS assessments. A telephone interview was conducted with the Administrator/Alternate Supervising Nurse on 09/12/2024 at 3:35 PM. The information regarding the “HHA Error Summary by Agency” report for the time-period of 05/12/2023 to 12/31/2023 was reviewed with the Administrator/Alternate Supervising Nurse. The Administrator/Alternate Supervising Nurse stated monitoring to ensure Agency nurses are completing documentation on time is a factor in ensuring OASIS assessments are submitted timely. The Administrator/Alternate Supervising Nurse stated the Agency’s electronic clinical record software system is set up to identify when the deadline for the OASIS assessment to be submitted is near. Review of Agency policy and procedure entitled, “OASIS Data [Encoding Locking and Reporting],” dated 01/2024, read in part, “All OASIS assessments are transmitted no later than 30 days from M0090 date.”