Every finding on record at Integracare Home Health Services, Inc.

A Recertification Survey entrance conference was conducted on 08/13/24 with the Administrator, Branch Director, and Area Director of Operations at 2:29 PM. Census L&CHHS: 74 An exit conference was conducted on 08/16/24 with Administrator, Branch Director, Area Director of Operations, Director of Clinical Operations, Area Vice President of Operations, Regional Vice President of Operations, Area rehab director, and Area director at 12:30 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.

A Recertification Survey entrance conference was conducted on 08/13/24 with the Administrator, Branch Director, and Area Director of Operations at 2:29 PM. Census L&CHHS: 74 An exit conference was conducted on 08/16/24 with Administrator, Branch Director, Area Director of Operations, Director of Clinical Operations, Area Vice President of Operations, Regional Vice President of Operations, Area rehab director, and Area director at 12:30 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: L&CHHS: Licensed and Certified 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, a tool used by CMS to collect certain patient information, to the CMS system within 30 days of completing the assessment of the patient for 10 of 717 assessments processed for the time-period reviewed of 05/12/2023 to 12/31/2023. 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 05/12/2023 to 12/31/2023 was reviewed. Review of the HHA Error Summary Report for the time period of 05/12/2023 to 12/31/2023 identified Error #-3330. The description for Error #-3300 read in part, “Record Submitted Late: The submission date was 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 10 assessments and the percentage of assessments with this error was 1.39% of assessments completed by the Agency. An interview was completed with the Administrator on 08/16/2024 at 11:55 AM. The HHA Error Summary Report for the time period of 05/12/2023 to 12/31/2023 was reviewed with the Administrator. The Administrator stated that the Agency had a process of assessment, quality assessment, coding, and corrections that involved multiple parties and occasionally the data was submitted late during the process. Review of the Agency’s policy titled “03-05 Patient Assessments”, dated 08/2024, revealed that “OASIS data items will be collected and transmitted within 30 calendar days of the completion of the OASIS assessment.”