Every finding on record at Hallmark Homecare LP

A Recertification Survey entrance conference was conducted on 10/21/24 with the Administrator at 10:42 AM. Census L&CHHS: 184 LHHS: 290 An exit conference was conducted on 10/24/24 with the Administrator, Alternate Administrator, Supervising Nurse, Quality Outcome Specialist, Regional President, Vice President of Quality Affairs, Director of Regulatory Affairs, Clinical Auditor, Senior Clinical Auditor, Quality and Outcome Specialist 2, and Senior Quality and Outcome Specialist at 2:30 PM. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations/Acronyms/Definitions L&CHHS: Licensed and Certified Home Health Services LHHS: Licensed Home Health Services CMS: Centers for Medicare & Medicaid Services OASIS: Outcome and Assessment Information Set iQIES: Internet Quality Improvement and Evaluation System HHA: Home Health Agency

A Recertification Survey entrance conference was conducted on 10/21/24 with the Administrator at 10:42 AM. Census L&CHHS: 184 LHHS: 290 An exit conference was conducted on 10/24/24 with the Administrator, Alternate Administrator, Supervising Nurse, Quality Outcome Specialist, Regional President, Vice President of Quality Affairs, Director of Regulatory Affairs, Clinical Auditor, Senior Clinical Auditor, Quality and Outcome Specialist 2, and Senior Quality and Outcome Specialist at 2:30 PM. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations/Acronyms/Definitions L&CHHS: Licensed and Certified Home Health Services LHHS: Licensed Home Health Services CMS: Centers for Medicare & Medicaid Services OASIS: Outcome and Assessment Information Set iQIES: Internet Quality Improvement and Evaluation System HHA: Home Health Agency

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 encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the patient for 113 of 6077 assessments processed for the time-period reviewed of 10/20/2023 to 10/20/2024. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare and improve patient care failing to be reported to CMS in the required time frame. Findings included: The HHA Error Summary Report, retrieved from the iQIES website for the time period of 10/20/2023 to 10/20/2024 was reviewed. Review of the HHA Error Summary Report for the time period of 10/20/2023 to 10/20/2024 identified Error #-3330. The description for Error #-3300 read in part, “Record Submitted Late: The submission date is more than 30 days after M0090 (item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with this error was 113 assessments and the percentage of assessments with this error was 1.86% of assessments completed by the Agency. An interview was completed with the Administrator on 10/24/2024 at 2:25 PM. The HHA Error Summary Report for the time period of 10/20/2023 to 10/20/2024 was reviewed with the Administrator. The Administrator stated that as of January 2023 the Agency had begun running weekly reports to flag when assessments were due to be submitted to OASIS but they recognized that assessments were late in the past. Weekly reports are not run to show which ones are past due and which ones are about to be due soon. Administrator was unable to identify a specific reason for why assessments are late and that is why they started running reports more frequently. Surveyor asked how this impacted client care. Administrator reported that she did not feel like it impacted client care and that it was more of a logistics issues. Review of the Agency’s policy titled “OASIS data collection A22”, dated 10/10/2023, revealed that “the Agency completed encoding; editing and locking of OASIS data within seven days of when the assessment is completed” and that “the Agency transmits OASIS data to the state agency no less than monthly.