Every finding on record at Jhs Operations, LLC

A recertification survey entrance conference was conducted on 11/06/24 at 8:20 am. Census: 153 Licensed and Certified- 147 Licensed Home Health- 6 The preliminary findings were discussed. The agency is in substantial compliance with no deficiencies cited.

A recertification survey entrance conference was conducted on 11/06/24 at 8:20 am. Census: 153 Licensed and Certified- 147 Licensed Home Health- 6 Acronyms used: CMS- Center for Medicare and Medicaid Services iQIES- Internet Quality Improvement and Evaluation System OASIS- Outcome and Assessment Information Set

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 did not code and electronically submit 18 patient’s OASIS data to iQIES (electronic system used to transmit quality measures from the OASIS data collected during comprehensive assessments) within 30 days to track and evaluate changes in the patient’s health while admitted to home health services to help ensure quality healthcare for patients for 8 of 12 months reviewed. This failure prevented the agency’s patient OASIS data from being made available to CMS for analysis of patient care performance. Findings included: Record review of an iQIES Error Summary Report dated 11/04/23 to 11/04/24 generated by the surveyor during pre-survey indicated the agency failed to code and electronically transmit 20 OASIS assessments data to the CMS system within thirty days of completing the assessment of the beneficiary. The iQIES Error Summary Report dated 11/04/23 to 11/04/24 indicated the assessments were for 18 patients and occurred in 8 of the 12 months. During an interview on 11/08/24 at 1:15 p.m., the Administrator/ Supervising Nurse said the Alternate Administrator/ Alternate Supervising Nurse reviewed the completed OASIS assessments. The Administrator/ Supervising Nurse said the Alternate Administrator/ Alternate Supervising Nurse then locked the assessments and sent them to corporate to be transmitted. The Administrator/ Supervising Nurse said there was a corporate department that was responsible for transmitting the OASIS assessments. The Administrator/ Supervising Nurse said she believed the corporate department submitted the assessments after 5-7 days. During a telephone interview on 11/08/24 at 1:25 p.m., the Alternate Administrator/ Alternate Supervising Nurse said she was responsible for reviewing the OASIS assessments for accuracy, consistency, and the coding. The Alternate Administrator/ Alternate Supervising Nurse said she locked the OASIS assessment once she was done. The Alternate Administrator/ Alternate Supervising Nurse said she did not transmit the OASIS assessment to CMS. The Alternate Administrator/ Alternate Supervising Nurse said she did not send the OASIS assessments to corporate to be transmitted. The Alternate Administrator/ Alternate Supervising Nurse said she was unsure how corporate got the OASIS assessments to transmit them. During an interview on 11/08/24 at 1:40 p.m., the Administrator/ Supervising Nurse reviewed the iQIES OASIS Error Report from 11/04/23 to 11/04/24. The Administrator/ Supervising Nurse agreed the report indicated the agency had 20 assessments for error number 3330. The error message for error number 3330 within the report indicated the submission date was more than 30 days after M0090 (the date of completion of the assessment). The Administrator/ Supervising Nurse said she was unaware of the iQIES Error Report or that the agency had assessments that were transmitted late. The Administrator/ Supervising Nurse reviewed the “Encoding and Reporting OASIS Data” policy and said the OASIS assessments should have been transmitted within 30 days of completion. The Administrator/ Supervising Nurse said she was unsure why the OASIS assessments were transmitted late. The Administrator/ Supervising Nurse said she could not imagine the assessments being held for 30 days at the agency level. Record review of a “Encoding and Reporting OASIS Data” policy dated 09/09/20 revealed, “… the agency will report all OASIS data collected in accordance with federal regulations. ... The agency will submit individual client assessment data within thirty (30) days of completing the comprehensive assessment. When the data is locked, it is transmitted to the iQIES system. This is to be done within 30 days of the day the OASIS was completed. …”