Every finding on record at E Care Home Health Services Inc

Purpose of visit: Recertification survey Entrance conference date: 11/19/2024 The census was - 10 Licensed and Certified patients – 10 No deficiencies were cited.

Purpose of visit: Recertification survey Entrance conference date: 11/19/2024 The census was – 10 Licensed and Certified patients – 10 Abbreviations: Adm - Administrator CMS - Centers for Medicare & Medicaid Services DON - Director of Nurses HHA – Home Health Agency IQIES - IQIES - Internet Quality Improvement and Evaluation System OASIS - Outcome and Assessment Information Set

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 completed OASIS (a standardized data set that measures the quality and outcomes of home health patients) assessments to the CMS system for all Medicare patients within 30 days of completing the OASIS assessment of the beneficiary (patients) for 56.47% (48 of 85) of assessments transmitted during 11/18/2023 to 11/18/2024. This failure prevented the agency’s patient data from being made available to CMS within 30 days of the OASIS completion dates for analysis to identify agency performance levels in the provision of patient care. Findings included: During pre-survey activity on 11/18/2024: The surveyor reviewed the agency OASIS report titled, “HHA Error Summary by Agency” from IQIES (an internet-based system that includes survey and certification functions) during the one-year of 11/18/2023 to 11/18/2024. The HHA Error Summary by Agency report included 48 of 85 OASIS assessments (56.47%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment. An interview was conducted with the Adm/DON on 11/19/2024 at 1:25 p.m. The Adm/DON said he was responsible for OASIS assessment submission to the CMS system. The surveyor asked what the agency policy for OASIS assessment submission was. Adm/DON said it’s 30 days. The surveyor reviewed the error summary report which included 48 of 85 OASIS assessments submitted late and asked what tracking system agency had to ensure timely submission of OASIS assessments. The Adm did not dispute the findings said there is no tracking system, he was the one who did the OASIS assessments, but forgets to submit on time which resulted in the agency not following its policy. Agency Policy titled, "8.10 TIMELINES” with a revision date of 1/29/2020, read in part “The Agency will ensure timely …... record information. Completed …. Within thirty (30) days of the M0090 date.