Every finding on record at Healthsource Home Care Inc

A re-certification survey entrance conference was conducted on 10/08/2024 at 11:28 AM. Census: L&C - 11 LHHS - 0 PAS - 0

A re-certification survey entrance conference was conducted on 10/08/2024 at 11:28 AM. Census: L&C - 11 LHHS - 0 PAS - 0

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 assessments [ a group of data elements developed by the Centers for Medicare and Medicaid (CMS), represent core items of a comprehensive assessment for an adult home care patient, form the basis for measuring patient outcomes, and determine agency reimbursement.] within 30 days of completion date for 12 of 12 months (August 2023 through August 2024) of transmissions reviewed. This failure prevented patient's data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. The Findings Included: Record review of pre -survey report on 10/09/2024, titled “HHA ERROR Summary by Agency” for reporting period 08/01/2023 to 08/31/2024 revealed that the agency had 342 (69.30) assessments with error warning of “-3330: Record Submitted late: The submission date is more than 30 days after M0090 [assessment] on this record”. In an interview on 10/08/2024 at 11:38am the ALT ADM stated the DON was responsible for OASIS transmittals. When asked if she was aware that there were over 300 records submitted late in OASIS, she stated she was unaware. Surveyor made multiple attempts to contact the DON with no success. In an interview on 10/09/2024 at 11:45 a.m. with the DON, regarding the OASIS transmittals, she stated that the alternate admin was responsible for transmitting the OASIS reports and she was only responsible for the assessments. When asked if she was submitting the assessments timely for them to be submitted, she stated she submitted them within 5 days of the assessment. The DON also voiced she was new to the position, and she was learning. In an interview on 10/09/2024 at 4:06 p.m. the ALT ADM was requested to print the 12 months error validation report. She voiced her understanding and began printing the validation report for the month requested. Review of the requested documents for August 2023 – August 2024, showed 342 assessments with the error number -3330 warning with error message; “Record Submitted late: The submission date is more than 30 days after M0090 [assessment] on this record.” Multiple records indicated a late transmittal of greater than 60 days. In an interview on 10/9/2024 at 4:22 p.m. the ALT ADM was asked what the agency’s policy was for submitting OASIS. The ALT ADM stated the nurses have 5 days to complete the OASIS assessments so that she was able to submit timely, but the nurses had not been completing the OASIS assessments on time so she was not able to submit them before the 30 days. When asked if the agency had implemented any corrective actions for the late assessments, the ALT ADM stated there were no corrective actions in place other than addressing the nurse multiple times about completing the assessments timely, until they were completed. She stated she was unaware of the number of late OASIS transmittals, but she was new to the position and was learning. When asked what her plan was moving forward with this information, she stated she would make herself knowledgeable and aware of the CMS guidelines for OASIS submissions. In an interview on 10/10/2024 at 1:08 pm with the ADM she was asked if she knew the policy for OASIS transmittals. She stated she did not know. She was asked if she was aware of the late transmittals, she stated she was unaware. When asked who was in charge of the agency to ensure that the OASIS was transmitted timely, she stated the ALT ADM was in charge. Review of the agency’s policy titled “Reporting of OASIS Information”, revised 1/13/2018, read in part: “……. The agency will report electronically all OASIS data collected in accordance with 484.55…. The agency will electronically transmit accurate, completed, and encoded, and locked OASIS data for each Medicare / Medicaid patient at least monthly to the State agency or CMS OASIS contractor….. For all assessments completed in the previous month, the agency will transmit data in accordance with current CMS transmission policy….”