Every finding on record at Fellowship Health Team LLC

A recertification survey was conducted on 02/18/2026. The census was: Licensed and Certified Home Health Services: 277; Licensed Home Health Services: 0. The agency was in compliance with no deficiencies cited.

A recertification survey was conducted on 02/18/2026. The census was: Licensed and Certified Home Health Services: 277; Licensed Home Health Services: 0. Abbreviations: Adm – administrator CMS – Centers for Medicare & Medicaid Services HHA – home health agency IM – information management 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 (patient) for 63.11% (1707 of 2705) of assessments transmitted during 11/01/2024 – 02/02/2026 and for 85.16% (155 of 182) assessments transmitted during 01/24/2026 - 02/17/2026. This failure prevented the agency’s patient data from being made available to CMS within 30 days of the OASIS completion date for analysis to identify agency performance levels in the provision of patient care. Findings included: During pre-survey activity on 02/02/2026: 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) for the period of 11/01/2024 – 02/02/2026. The report included 1707 of 2705 OASIS assessments (63.11%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment. An interview was conducted with the Adm on 02/10/2026 at 3:30 PM. The Adm stated she was responsible for submitting OASIS assessments to the CMS system. On 02/17/2026, a second report titled, “HHA Error Summary by Agency” was reviewed for the period of 01/24/2026 - 02/17/2026. The report included 155 of 182 OASIS assessments (85.16%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment, a 22.05% increase. Record review of the Adm personnel file on 02/18/2026 included a job description for the Adm position signed and dated by the Adm on 11/03/2025. During an interview with the Adm on 02/17/2026 at 2:47 PM, the surveyor asked why 63.11% (1707 of 2705) OASIS assessments for dates 11/01/2024 - 02/02/2026 were submitted past 30 days of completion date. The Adm stated she had noticed OASIS assessments had not been submitted proactively, which was part of the reason she took the task over approximately one month ago, which resulted in an improvement with timely submissions. The surveyor reviewed the error summary report for period 01/24/2026 - 02/17/2026 with the Adm that included 155 of 182 OASIS assessments (85.16%) were submitted more than 30 days of completing the OASIS assessment. The surveyor asked why the issue had worsened and not been corrected since taking over the submissions. The Adm stated the nurses were completing the assessments late which resulted in the assessments being submitted to CMS after 30 days of completion. The Adm further stated the nurses had gotten better at completing the assessments within 30 days, but then the assessments were reviewed by the quality assurance department which further delayed the process. The Adm stated agency policy was not followed because the nurses were late with OASIS documentation and the quality assurance department was even slower. Agency policy titled, “IM.10 OASIS Collecting, Encoding and Transmitting” with a revision date of 01/01/2021 read in part, “… Procedure… The Agency must encode and electronically transmit each completed OASIS assessment to the CMS system, for each beneficiary with respect to which information is required to be transmitted within 30 days of completing the assessment of the beneficiary…”