Every finding on record at Infinite Care Home Health Inc

An entrance conference was conducted for relicensure and recertification with the Administrator on 9/27/2024 at 09:00 a.m. The Administrator was informed of the purpose of the survey. Midlothian: Census: 398 Licensed and Certified Home Health: 398 Licensed Home Health: 0 Personal Assistant Services: 0 Hospice: 0 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 Violations. NO DEFICIENCIES WERE CITED

Administrator on 9/27/2024 at 09:00 a.m. The Administrator was informed of the purpose of the survey. Midlothian: Census: 398 Licensed and Certified Home Health: 398 Licensed Home Health: 0 Personal Assistant Services: 0 Hospice: 0 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 Violations. Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services PAS - Personal Assistance 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 31 of 2285 assessments processed for the time period reviewed of 05/31/2023 - 12/31/2023. 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. Findings included: The HHA Error Summary Report, retrieved from the iQIES website for the time of 05/31/2023 - 12/31/2023 was reviewed. Review of the HHA Error Summary Report for the time-period of 05/31/2023 - 12/31/2023 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 this error was 31 assessments. During an interview conducted with the Administrator and Supervising Nurse on 10/1/2024 at 2:00 p.m. The HHA Error Summary Report was reviewed with the Administrator. The Administrator stated the Agency was aware of the late submissions of OASIS assessments due to resubmission delay between the dates of 05/31/2023 - 12/31/2023. The Administrator further revealed that the Agency usually transmits the assessments timely but may have resubmitted the assessments after the 30-day threshold after making corrections to the assessments. The Administrator further stated that she believed the agency was under an allowable 10% threshold of late OASIS submissions. Record review of an Agency policy titled, "IM.10 OASIS Collecting, Encoding and Transmitting" dated 1/1/2021, read in part, “1. The Agency must encode and electronically transmit each completed OASIS assessment to the CMS system, for each beneficiary with respect to which information is required to be transmitted within 30 days of completing the assessment of the beneficiary.”