Every finding on record at Life Home Health Care Inc

Purpose of Visit – To conduct a Recertification Survey and follow up survey. Entrance Date/Time - On 02/04/25 at 01:45 p.m., the surveyor conducted an unannounced visit and an entrance conference with the Alternate Administrator (Alt Adm). Census: Licensed and Certified: 31 The agency was in compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies. No deficiencies. Administrator - Adm Alternate Administrator – Alt Adm

Purpose of Visit – To conduct a Recertification Survey and follow up survey. Entrance Date/Time - On 02/04/25 at 01:45 p.m., the surveyor conducted an unannounced visit and an entrance conference with the Alternate Administrator (Alt Adm). Census: Licensed and Certified: 31 An exit conference was conducted on 02/07/25 at 12:00 pm with the Alt Adm. Administrator - Adm Alternate Administrator – Alt Adm

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 completion in 7 of 8 months of transmissions reviewed (February 2024, May 2024, July 2024, August 2024, September 2024, October 2024, and November 2024. This failure prevented the patient’s data from being made available to Center for Medicare and Medicaid (CMS) for analysis to identify agency performance levels in the provision of patient care. The findings included: Record review of IQIES “Home Health Error Summary by Agency” report generated from the CMS national data system during presurvey preparation on 02/04/25 revealed Agency had submitted and processed 262 OASIS assessments to CMS. The report also revealed the Agency had 13 OASIS assessments with error -3330 indicating those records were submitted after the 30th date of the M0090 (assessment) date, which equaled to 5% of the total assessments submitted in error. Record review of the OASIS Agency Final Validation report with submission date of 02/12/24 at 07:49 am revealed 5 total records were submitted. Further review of this report revealed 1 of the 5 (record 3) records processed with error -3330 indicating that record was submitted after the 30th date of the M0090 date. Record review of the OASIS Agency Final Validation report with submission date of 02/27/24 at 08:28 am revealed 4 total records were submitted. Further review of this report revealed 1 of the 4 (record 2) records processed with error -3330 indicating that record was submitted after the 30th date of the M0090 date. Record review of the OASIS Agency Final Validation report with submission date of 05/23/24 at 07:32 am revealed 6 total records were submitted. Further review of this report revealed 1 of the 6 (record 1) records processed with error -3330 indicating that record was submitted after the 30th date of the M0090 date. Record review of the OASIS Agency Final Validation report with submission date of 07/13/24 at 07:53 am revealed 4 total records were submitted. Further review of this report revealed 1 of the 4 (record 4) records processed with error -3330 indicating that record was submitted after the 30th date of the M0090 date. Record review of the OASIS Agency Final Validation report with submission date of 08/08/24 at 06:57 am revealed 5 total records were submitted. Further review of this report revealed 1 of the 5 (record 4) records processed with error -3330 indicating that record was submitted after the 30th date of the M0090 date. Record review of the OASIS Agency Final Validation report with submission date of 09/13/24 revealed 11 total records were submitted. Further review of this report revealed 3 of the 11 (record 3, 9 and 11) records processed with error -3330 indicating those records were submitted after the 30th date of the M0090 date. Record review of the OASIS Agency Final Validation report with submission date of 10/01/24 revealed 11 total records were submitted. Further review of this report revealed 2 of the 11 (record 4 and 10) records processed with error -3330 indicating those records were submitted after the 30th date of the M0090 date. Record review of the OASIS Agency Final Validation report with submission date of 11/08/24 revealed 13 total records were submitted. Further review of this report revealed 3 of the 13 (record 1, 4 and 13) records processed with error -3330 indicating those records were submitted after the 30th date of the M0090 date. In an interview on 02/07/25 at 11:30 a.m., Alt Adm stated Alt Adm was responsible for reporting OASIS assessments to CMS. Alt Adm stated Alt Adm was responsible for making sure the OASIS validation reports were sent timely to CMS. Alt Adm stated the submissions were late when the Registered Nurse completes the assessments late. In an interview on 02/07/25 at 11:30 a.m., Alt Adm stated that the Agency’s current process to track OASIS data transmission to CMS consists of a clinician turning in their notes and Quality Assurance (QA) reviews and returns to clinician for corrections. This way the Agency keeps a tally of the timeframes for OASIS data transmissions. Agency currently keeps a report that tells the Alt Adm which OASIS transmissions may be outstanding. As per Alt Adm, most of the late entries are due to Medical Doctor no signing the discharge orders timely as well as clinicians taking long to return the corrected notes timely. In an interview on 02/07/25 at 11:30 a.m., Alt Adm stated that failing to provide patient pertinent data to CMS could have a negative impact to the Agency’s active patients in that there could be a delay on payment from CMS as well as Agency’s performance data would be compromised. Agency policy titled "Administrative Policy Manual" with revision date of 12/01/2014 revealed in part: "...Timelines...1.11 Completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic standards. It will be transmitted to CMS OASIS contractor within 30 days of the M0090 date..." The agency was afforded the opportunity to provided additional information, no other information provided upon exit 02/07/25 at 12:00 pm.