Every finding on record at Gilbert's Home Health Agency, Inc.

*EMERGENCY PREPAREDNESS* Survey conducted on 07/29-08/01/2024 revealed the above facility meets all applicable Federal, State and local emergency preparedness requirements. No violations identified.

*TUPELO* The Medicare Recertification survey conducted 07/29 - 08/01/2024 revealed the facility has met all Medicare Conditions of Participation for Home Health. However, Standard level deficiencies were identified as follows..... ______________

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 staff interview, policy and procedure review, and review of the facility report “HHA error summary by agency”, the facility failed to encode and electronically transmit each completed Outcome and Assessment Information Set (OASIS) assessment within 30 days of completing the assessment of the beneficiary for 78 patients in the past 12 months: 07/25/2023 – 07/25/2024. Findings Include: An interview with the Facility Director and Branch Director on 07/31/2024 at 10:00 a.m. confirmed the agency is to submit OASIS data per Centers for Medicare and Medicaid services within 30 days of completing Oasis Data Sets. Review of the facility Internet Quality Improvement and Evaluation System (IQIES) report, “The HHA Error summary report by Agency”, for the past 12 months revealed, Error -3330 for 78 patient assessments submitted late within 30 days of completing the assessment of the beneficiary. Review of facility’s job aid, “QAO (Quality Assessment Only) and OASIS Timely Submission” revised 04-2024, confirmed “…Submit “timely” OASIS assessments defined as within 30 days of M0090…”. No policy and procedure for submission of OASIS assessments was submitted for review. During the exit conference on 08/01/2024 at 11:00 a.m. with Branch Director #1, #2, #3, and #4, Director of Clinical Operations and Area Vice President of Operations, survey findings were discussed, and no further documentation was submitted for review.