Every finding on record at Encompass Home Health of East Texas LLC

A recertification survey entrance conference was conducted on 12/01/25. The agency was in compliance with no deficiencies cited. Census- 1 Licensed and Certified- 1 Licensed Home Health- 0

A recertification survey entrance conference was conducted on 12/01/25. Census- 1 Licensed and Certified- 1 Licensed Home Health- 0 Acronyms: OASIS- Outcome and Assessment Information Set CMS- Centers for Medicare and Medicaid Services CPMS- Care Plan Management Specialist IQIES- Internet Quality Improvement and Evaluation System 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 interview and record review, the agency failed to code and electronically transmit each completed OASIS (data collected as part of the comprehensive assessment) assessment to the CMS system within thirty days of completing the assessment of the beneficiary for 2 of 12 assessments submitted (16.67%). The agency did not code and electronically submit 2 patient’s OASIS data to IQIES (electronic system used to transmit quality measures from the OASIS data collected during comprehensive assessments) within 30 days to track and evaluate changes in the patient’s health while admitted to home health services to help ensure quality healthcare for patients. This failure prevented the agency’s patient OASIS data from being made available to CMS for analysis of patient care performance Findings included: Review of an IQIES Error Summary Report dated 11/26/24 to 11/26/25 generated by the surveyor during pre-survey on 11/26/25 indicated the agency failed to code and electronically transmit 2 of 12 OASIS assessments data to the CMS system within thirty days of completing the assessment of the beneficiary. During an interview on 12/01/25 at 12:09 p.m., the Administrator said when OASIS (assessment) came from the field it went to workflow to an RN and was then reviewed by an RN. She said corrections were made then it was locked, and from there it went to billing. The Administrator said she didn’t know if billing sent it to IQIES and asked what IQIES was. The Administrator said OASIS was locked and submitted and anything past 30 days was considered late. During an interview on 12/01/25 at 1:45 p.m., the Administrator said Director of Venue Cycle E did OASIS submissions. During a concurrent interview on 12/02/25 at 9:35 a.m. with Director of Venue Cycle E and VP of Regional Affairs F, the Director of Venue Cycle E said someone on her team was responsible for submitting OASIS to IQIES. She said the branch/agency reviewed the OASIS and locked them, then sent them to her team. She said her team sent OASIS to Software K (cloud-based software that provides end-to-end revenue cycle management solutions to simplify healthcare payments and accelerate financial results) and Software K submitted OASIS to IQIES and pulled the validation reports back. She said there was one person on her team who submitted OASIS and a backup when she was out of office. Surveyor requested to speak to this person who did OASIS submissions and Director of Venue Cycle E said she covered for that person when she was out, and she could answer all questions the surveyor had. Director of Venue Cycle E said OASIS submission timeframe to IQIES was 30 days from the visit. When surveyor asked if she was aware any were late, she said she ran the error summary report and saw there were 2 that were late for this location. She said a potential negative outcome for submitting late OASIS was if the agency was not at 90% or more in compliance with submissions being timely; the agency would have a 2% penalty for the entire fiscal year. She said this penalty was from CMS and the agency would get a letter for non-compliance, and it was posted in IQIES. VP of Regional Affairs F said another negative outcome could also be survey deficiency because 90% of OASIS had to be submitted timely. During an interview on 12/02/25 at 10:08 a.m., the Administrator said the reason for late OASIS submissions was because previously the agency had a CPMS team who reviewed packets, audited charts, and sent in locked OASIS, etc. She said in December of last year (2024) the agency eliminated those positions. She said packets were coming back to the branch/office and the office “tiered” them. She said during this it was identified they (CPMS) were not able to keep up. She said packets were given back to the agency and everything wasn’t done. She said the packets were handed over to the agency in February and that was when the agency took over OASIS. She said previously when OASIS would come in from the field the CPMS team would send OASIS to Director of Venue Cycle E’s team once it was locked, and Director of Venue Cycle E’s team would send OASIS to the state agency. She said this occurred until the CPMS team was eliminated. Record review of an OASIS Data Collection policy dated 10/28/25 indicated “…4.4 The Agency transmits OASIS data to the state agency no less than monthly. 4.4.1 At designated intervals, no less frequent than once a month, the Claims Specialist connects via designated software to the state agency. All OASIS data set records collected from the previous month are uploaded to the state agency…”