Every finding on record at L&Joe LLC

Purpose of Survey – To conduct a Relicensure, recertification, and follow up to survey conducted 09/22/22. On 08/20/25, the surveyor conducted an unannounced visit to the Agency. Census- Licensed and Certified Home Health Services (LCHHS) – 25 Licensed Home Health Services (LHHS)– 0 The Agency was in substantial compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies. Abbreviations: Adm – Administrator CFR – Code of Federal Regulations DON – Director of Nurses LCHHS – Licensed and Certified Home Health Services LHHS – Licensed Home Health Services.

Purpose of Survey – To conduct a Recertification and follow up to survey conducted 09/22/22. On 08/20/25, the surveyor conducted an unannounced visit to the Agency. Census- Licensed and Certified Home Health Services (LCHHS) – 25 Licensed Home Health Services (LHHS)– 0 An exit conference was conducted on 08/26/25 with the Adm/DON. The preliminary findings were discussed. Abbreviations: Adm – Administrator CMS – Centers for Medicare and Medicaid DON – Director of Nurses HCSSA – Home and Community Support Services Agencies FIPS – Federal Information Processing Standard IQIES – Internet Quality and Improvement Evaluation System LCHHS – Licensed and Certified Home Health Services LHHS – Licensed Home Health Services OASIS – Outcome and Assessment Information Set QA – Quality Assurance RN – Registered Nurse TAC – Texas Administrative Code

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 transmit completed OASIS (Outcome and Assessment Information Set) Assessments within 30 days of completions for 408 of 532 assessments submitted between 08/01/24 through 08/20/25. This failure prevented the patient’s data from being made available to the Centers for Medicare and Medicaid (CMS) for analysis to identify Agency performance levels in the provision of patient care. Findings included: Record review of the IQIES (Internet Quality and Improvement Evaluation System, an internet-based system that consolidates and replaces legacy systems for survey and certification functions) “Home Health Error by Summary Agency” report generated by the CMS national data system during presurvey preparation on 08/19/25 revealed the Agency had submitted and processed 408 assessments. The report indicated the Agency had a 70.98% of assessments with -3330 error that indicated the assessments were submitted after the 30th date of the M0090 date. Record review of the Agency OASIS final validation reports dated 08/01/25 through 08/20/25 revealed 532 were processed by the Agency. Further review of the Agency OASIS final validation reports revealed 408 of the 532 assessments had error -3330 indicating those records were submitted after the 30th date of the M0090 date. In an interview on 08/26/25 at 10:50 a.m., the Adm/DON stated the Agency’s policy for submitting OASIS assessments were within 30 days. The Adm/DON stated she was responsible for the oversight of OASIS assessments and to ensure they were submitted within 30 days. The Adm/DON the Agency was aware they were submitting OASIS assessments after the 30 days because the Agency had gone through personnel change. The Adm/DON stated, “we knew there was an issue with these nurses” because they were not submitting these reports in a timely manner. The Adm/DON stated Agency had two (2) QA nurses who were “no longer with the Agency” and they were responsible at the time for submitting the OASIS assessments. The Adm/DON stated she now held that position and was responsible for exporting OASIS reports to CMS until the Agency hired new personnel who could “fill the QA nurse position”. The Adm/DON stated the Agency’s process for submitting OASIS after admitting a client to the Agency included assigning an RN to perform the assessment. The Adm/DON continued detailing the process stating that once the assessment was completed the nurse would then submit the assessment to QA who would then do one of two options. The Adm/DON stated QA would review the assessment and either send it back to the assigned nurse for corrections or export the assessment to CMS. The Adm/DON stated the QA nurses would not generate the reports required to keep track of the assessments. The Adm/DON stated, “that is where our system was broken because our QA nurses were either not submitting them [OASIS assessments] entirely in a timely manner or they [QA nurses] were submitting a lot of duplicates but they [OASIS assessments] were all late”. The Adm/DON stated not submitting OASIS assessments within the 30 days could negatively affect client care and the Agency because the Agency was “noncompliant” and that because the client “information that compared the Agency to other Agencies and the trends from the assessments pulled by CMS could be delayed”. Record review of the Agency policies titled, “Timelines, IM.35”, with a revised date 07/01/25, quoted in part, “The Agency will ensure timely provision of care and services to meet the patient’s/client’s needs in compliance with all federal and state laws and regulations…II. All completed and encoded OASIS data will be transmitted via electronic communications software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set and the CMS-assigned branch identification number, as applicable. It will be transmitted using electronic communications software that compiles with Federal Information Processing Standard (FIPS 140-2, issued May 20, 2001) from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date…”