Every finding on record at Horizon Health Care Inc

An entrance conference was conducted for a Relicensure and Recertification survey with the Administrator on 7/8/2024 at 4:00 p.m. Census El Paso: 125 Licensed and Certified Home Health: 125 Licensed Home Health: 0 Personal Assistant Services:0 Exit conference was conducted on 7/11/2024 at 6:00 p.m. with the Administrator. The preliminary findings were reviewed and discussed, and the agency was afforded the opportunity to provide additional information. NO DEFICIENCIES WERE CITED

An entrance conference was conducted for a Relicensure and Recertification survey with the Administrator on 7/8/2024 at 4:00 p.m. Census El Paso: 125 Licensed and Certified Home Health: 125 Licensed Home Health: 0 Personal Assistant Services:0 Exit conference was conducted on 7/11/2024 at 6:00 p.m. with the Administrator. The preliminary findings were reviewed and discussed, and the agency was afforded the opportunity to provide additional information. Written instructions for submitting an acceptable plan of correction within 10 calendar days of receipt of the Statement of Licensure Violations were provided. Abbreviations/Acronyms: 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 PT- Physical Therapist PTA Physical Therapy Assistant

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 759 of 1544 assessments processed for the time period reviewed of 05/12/2023 to 12/31/2024. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare failing to be reported to CMS in the required time frame. The findings included: The HHA Error Summary Report, retrieved from the iQIES website for the time period of 05/12/2023 to 12/31/2024 was reviewed. Review of the HHA Error Summary Report for the time-period of 05/12/2023 to 12/31/2024 identified Error #-3330. The description for Error #-3330 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 the error was 759 assessments and the percentage of assessments with this error was 49.16% of assessments completed by the Agency. A joint interview was conducted with the Administrator and Supervising Nurse on 7/11/2024 at 1:30 p.m. The HHA Error Summary Report was reviewed with the Alternate Administrator and Supervising Nurse. The Administrator stated the Agency was aware of the late submissions of OASIS assessments due to the Agency transitioning from one electronic medical record system to another and is working on correcting the issue. The Supervising Nurse stated the Agency currently has no Agency policy on timely OASIS submissions on record and is currently working on the issue. The Supervising Nurse also stated that the Agency frequently educated the Agency nurses on timely submission of documentation. The Administrator also revealed that she and the Nursing Supervisor are responsible for timely submissions of the OASIS assessments. Record review of an Agency policy titled, "Initial Patient Comprehensive Assessment " no date, read in part, "…Each patient will receive a patient specific, comprehensive assessment, which incorporates OASIS data set for Medicare/Medicaid patients, completed by a Registered Nurse, Physical Therapist or Speech Therapist. The assessment will accurately reflect the patient’s current health status and assist in uniformly and consistently measuring patient outcomes. Medicare patient will be assigned a 60-day Episodic Rate based on the assessment. "