Every finding on record at Hackensack Meridian Ambulatory Care Inc

This report is the result of an unannounced Federal Recertification survey completed on April 30, 2026 at Hackensack Meridian JFK at Home. It was determined the facility is in substantial compliance with the requirements of Emergency Preparedness regulation 42 CFR 484.102, Condition of Participation for Home Health Agencies (HHAs) for this survey.

This report is the result of an unannounced standard-level Federal Recertification and State Re-licensure survey completed on April 30, 2026 at Hackensack Meridian JFK at Home. It was determined the facility is not in substantial compliance with Federal requirements of 42 CFR Part 484, Subpart B Conditions of Participation for Home Health Agencies and State requirements of N.J.A.C. Title 8 Chapter 42 Home Health Agency Licensing Standards.

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 review of facility policy, review of agency pre-survey report, and staff interviews, it was determined the facility failed to ensure timely transmission of Outcome and Assessment Information Set (OASIS) assessments within 30 days of completion of beneficiary assessments. Findings include: Facility policy titled, "OASIS Data Transmission," dated 05/2025, stated, "… Procedure 1. The organization will encode and electronically transmit completed OASIS data to the national internet Quality Improvement Evaluation System (iQIES) for each applicable patient within thirty (30) days of the … date assessment completed … 7. A tracking mechanism will be utilized by the organization to ensure accuracy and timeliness of OASIS data and transmission …" A review of the iQIES HHA (Home Health Agency) Error Summary by Agency report, with a reporting period of 03/01/25 to 04/23/26, revealed 826 assessments submitted to iQIES greater than 30 days after completion of the beneficiary assessments. The findings were confirmed with Staff (S) 1 on 04/29/26 at 3:18 PM. On 04/30/26 at 10:04 AM, an interview was conducted with S1, S2, S3, and S17. S3 stated facility leadership works with the billing team and runs reports to determine timeliness of OASIS assessment transmissions. When asked about their process on how often the facility is monitoring and tracking OASIS assessment transmissions, S1 stated "I don't know if we have a true cadence." S1 was unable to provide a written process or describe the facility's process for monitoring and tracking OASIS assessment transmissions. Cross reference: NJAC 8:42-6.1(a)