Every finding on record at Glory Able Home Healthcare Inc

A recertification survey was conducted on 08/05/2025. The census was 3 (Licensed and Certified) and 0 (Licensed Home Health). The agency is in compliance with no violation cited.

A recertification survey was conducted on 08/05/2025. The census was 3 (licensed & certified). Abbreviations: OASIS -outcome and assessment information set CMS- Center for Medicare and Medicaid Services IQIES – Internet Quality Improvement & Evaluation System PDF – Portable Document Format

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 transmit completed OASIS (a tool used by CMS to collect certain patient information) assessment to CMS within 30 days of completing the OASIS assessment, in that: from 01/01/2025 to 08/04/2025 there were 11 assessments transmitted greater than 30 days from the assessment completion date. This Failure prevented the agency's patient data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. Pre-survey review of the report titled, “OASIS Error Detail Report” taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed 11 (patients 1, 2 and 3) assessments contained error number -3330 with the error message of, “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record review for Patient 1: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 65098465 submission date 06/02/2025 with 2 total record processed. Record 1 (Patient 1) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 1 (Patient 1) of the OASIS Agency Final Validation report that was submitted on 06/02/2025 had a M0090 completion date of 04/23/2025. Record review for Patient 2: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 65098465 submission date 06/02/2025 with 2 total records processed. Record 2 (Patient 2) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 2 (Patient 2) of the OASIS Agency Final Validation report that was submitted on 06/02/2025 had a M0090 completion date of 04/23/2025. Record review for Patient 3: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 65182773 submission date 06/17/2025 with 3 total records processed. Record 3 (Patient 3) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 3 (Patient 3) of the OASIS Agency Final Validation report that was submitted on 06/17/2025 had a M0090 completion date of 04/23/2025. On 08/06/2025 at approximately 12:46 PM the surveyor conducted an interview with the Administrator. Surveyor: Who is responsible for transmitting completed OASIS assessments to CMS Administrator: I am Surveyor: What is your understanding of the timeframe the agency must transmit completed OASIS assessments to CMS according to the regulation Administrator: we want to do it as soon as possible but I know we have to do within 30 days. Surveyor: Who is responsible for assuring the agency meets the regulation for transmitting OASIS assessments to CMS within 30 days of the assessment Administrator: I am. Surveyor: During pre-survey the surveyor ran the OASIS error detail report. The report identifies any OASIS the agency transmits to CMS past 30 days. The report showed from 01/01/2025 thru 8/04/2025 the agency transmitted 11 OASIS assessments that were past 30 days from the assessment date. Do you know why the agency transmitted 11 OASIS assessments late. Administrator: I know we have issues to deal with the system when we export and I think that is what the problem was. Surveyor: During review of Patient 1’s medical record for the episode 4/26/2025 thru 6/24/2025 the surveyor found that an OASIS assessment was completed on 4/23/2025. Review of the OASIS final validation report showed the assessment was transmitted to CMS on 6/2/2025 which is greater than 30 days past the assessment date. Why was the OASIS assessment transmitted past 30 days. Administrator: It was actually due to the size of the file for the PDF. It kind of depends on what you use for the PDF when you submit to CMS. I know now I just stick to Software Z for the PDF to submit. I think that was the problem. Surveyor: During review of Patient 2’s medical record for the episode 4/26/2025 thru 6/24/2025 the surveyor found that an OASIS assessment was completed on 4/23/2025. Review of the OASIS final validation report showed the assessment was transmitted to CMS on 6/2/2025 which is greater than 30 days past the assessment date. Why was the OASIS assessment transmitted past 30 days. Administrator: I think the same thing happened Surveyor: During review of Patient 3’s medical record for the episode 4/26/2025 thru 6/24/2025 the surveyor found that an OASIS assessment was completed on 4/23/2025. Review of the OASIS final validation report showed the assessment was transmitted to CMS on 6/18/2025 which is greater than 30 days past the assessment date. Why was the OASIS assessment transmitted past 30 days. Administrator: It was the same Surveyor: If the agency does not transmit OASIS to CMS according to CMS regulation how could that effect the agency and agency clients Administrator: one, it would be that we lack in the compliance and that is not good. For the care of the client, it doesn’t affect their care. We still do the care. Review of Agency policy titled, “Timelines” with a revision date of 080120 read in part: “…II. All completed and encoded OASIS data… will be transmitted…from the Agency or the Agency contractor to the CMS collection site within thirty (30) days of the M0090 date.”