Every finding on record at Home Health Care Affiliates of Ms, Inc

*EMERGENCY PREPAREDNESS* Survey conducted on 04/21-04/24/2025 revealed the above facility meets all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.

*COLUMBUS * The Medicare Recertification survey conducted 04/21-04/24/2025 revealed the above facility has met all Medicare Conditions of Participation for Home Health Agencies (HHA). However, Standard-level deficiencies were cited. ___________________

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 interviews, 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 111 patients in the past 12 months: 04/18/2024-04/18/2025. Findings Include: An interview with Branch Director #1 on 04/21/2025 at 1:20 p.m. confirmed that Branch Directors have been informed by corporate of the possibility of a citation during a survey related to timely submission of OASIS data. Branch Director #1 also confirmed that OASIS data is to be submitted within 30 days of completion of the OASIS. Review of the facility’s Internet Quality Improvement and Evaluation System (iQIES) Report, “HHA Error Summary by Agency” dated 04/18/2024-04/18/2025 revealed, Error # -3330 for 111 patient assessments submitted late within 30 days of completing the assessment of the beneficiary between 04/18/2024-04/18/2025. Review of the facility’s policy, “Policy 03-05 Patient Assessments, Annual Review 08/2024, Revised 08/2024” revealed, “…OASIS data items will be collected and transmitted within 30 calendar days of the completion of the OASIS assessment…”. Review of the facility’s Quality Assessment Only (QAO) and OASIS Timely Submission Job Aid, revised 04/2024 which revealed, “…The QAO reporting performance system is driven by the principle that each HHA will be expected…submit “timely” OASIS assessments defined as within 30 days of M0090…”. During the Exit Conference on 04/24/2025 at 11:45 a.m. with Branch Director #1 and Branch Director #2, survey findings were discussed, and no further documentation was submitted for review.