Every finding on record at El Paso Nursing Services Inc

A Recertification Survey was conducted on 05/27/2025. The Agency census was: L&CHHS – 123 PAS – 0 The Agency was in compliance with no Emergency Preparedness deficiencies cited.

A Recertification Survey was conducted on 05/27/2025. The Agency census was: L&CHHS – 123 PAS – 0 Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services PAS – Personal Assistance Services HHA - Home Health Agency OASIS - Outcome and Assessment Information Set CMS - Centers for Medicare Services PRN – Pro re nata RN – Registered Nurse

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 67 out of 1100 of the assessments processed for the time-period reviewed of 5/27/2024 to 5/27/2025. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare and improve patient care failing to be reported to CMS in the required time frame and has the potential to place clients at risk of substandard care. Findings included: Review of the HHA Error Summary Report for the time-period of 5/27/2024 to 5/27/2025 identified Error #-3330. The description for Error #-3330 read in part, “Record Submitted Late: The submission date was 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 67 assessments and the percentage of assessments with this error was 6.09% of assessments completed by the Agency. An interview was conducted with the Operations Manager and via telephone with the Administrator/Supervising Nurse, and the Chief Executive Officer on 05/28/2025 at approximately 4:35 PM. Surveyor reviewed the HHA Error Summary Report for the time-period of 05/27/2024 to 05/27/2025 with the Operations Manager, the Administrator/Supervising Nurse and the Chief Executive Officer. The Operations Manager stated PRN (As needed) RN's may have contributed to the late OASIS submissions due to not completing or following-up on OASIS documentation in a timely manner. The Chief Executive Officer stated the Agency monitored OASIS submissions via an Open OASIS Report and the Administrator/Supervising Nurse, the Chief Executive Officer and the Operations Manager met daily to review the report. The Chief Executive Officer stated once the OASIS assessment is completed by the RN, it would go to the Coder and the expectation was that the process would be completed within 5 days. The Administrator/Supervising Nurse stated the Agency monitored timely submission of OASIS assessments as the Agency’s goal was to get them to create the Plan of Care and send to the Physician for signature.