Every finding on record at Jasper General Hospital

*EMERGENCY PREPAREDNESS* Survey conducted on 06/24-06/26/2024 revealed the above facility meets all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.

*BAY SPRINGS * The Medicare Recertification survey conducted 06/24-06/26/2024 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 interview, 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 41 patients in the past 12 months: 06/01/2023-06/20/2024. Findings Include: An interview with the Director of Nursing on 06/26/2024 at 1:51 p.m. confirmed the agency is supposed to submit OASIS data within 30 days of completing Oasis Data Sets. Review of the facility Internet Quality Improvement and Evaluation System (IQIES) report, “The HHA Error summary report by Agency”, dated 06/01/2023-06/20/2024 for 12 months revealed, Error -3330 for 41 patient assessments submitted late within 30 days of completing the assessment of the beneficiary. Review of facility’s policy, “Comprehensive Assessment and Oasis” revised 05/10/2024, confirmed “…The HHA must encode and be capable of transmitting OASIS data for each agency patient within 30 days of completing an OASIS data set…”. During the exit conference on 06/26/2024 at 3:30p.m. with the Administrator, Director of Nursing, Nurse Manager and Registered Nurse, survey findings were discussed, and no further documentation was submitted for review.