Every finding on record at Discovery at Home in Texas Inc

A re-licensure, re-certification survey was conducted on 7/25/2023. The census was Licensed and Certified: 115, Licensed Home Health: 0, Personal Assistance Services: 28. The agency was in substantial compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies.

A re-licensure, re-certification survey was conducted on 7/25/2023. The census was Licensed and Certified: 115, Licensed Home Health: 0, Personal Assistance Services: 28. QA: Quality Assurance CMS: Centers for Medicare & Medicaid OASIS: Outcome and Assessment Information Set IQIES: Internet Quality Improvement and Evaluation System

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 electronically transmit the completed OASIS assessment for 1 of 4 discharged patient records reviewed to the state agency within 30 days of completing the OASIS assessment of the patient. OASIS is a tool used by CMS to collect patient information. Citing Patient # 10 This failure prevented the agency's patient data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. Findings: The surveyor reviewed the OASIS transmission for the agency on the IQIES portal on 7/23/2024 as part of the preparation for the survey. On 7/23/2024 the surveyor requested from the agency Administrator the OASIS summary report for the last 12 months. Patient # 10 Review of the OASIS summary report revealed Patient #10's discharge date as 5/1/2024. The report documented the date of the discharge assessment as entered by the agency at OASIS assessment item M0090 was 5/1/2024. The report documented that the submission date of the discharge assessment was 6/7/2024. The report documented the following error message: "Record Submitted Late: The submission date is more than 30 days after M0090 on this new record." An interview was conducted with the agency Administrator on 7/25/2024 at approximately 11:30 a.m. The surveyor inquired as to what was the agency's process for submitting OASIS assessments. The Administrator stated, "...The nurse submits to QA, we code it and review, finalize and approve. The billing department does the export process..." The surveyor inquired as to why the agency was not following the policy for submitting OASIS. The Administrator stated, "...We got back logged on having enough staff. We were having an issue with our coders. We let them go and a new company is doing it..." The surveyor inquired as to whose responsibility it is to make sure that the OASIS submissions are completed and exported according to policy. The Administrator stated, "...Mine..." Review of the agency's policy titled, "...Timelines IM.35 Page 2 of 2 Last Reviewed 050224..." read, in part, "...II. All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS...from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date..."