Every finding on record at Lipet Home Care Inc

On 05/08/2024 a re-certification survey was conducted. The agency was found in compliance with 42 CFR Part 484.22 Emergency Preparedness Requirements for Home Health Agencies and no deficiencies were cited. Census: Licensed and Certified: 0 CFR - Code of Federal Regulations

On 05/08/2024 a re-certification survey entrance was conducted. Census: Licensed and Certified: 0 An exit Conference was conducted on 05/13/2024 with the Administrator at 11:14 AM. 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: OASIS -outcome and assessment information set CMS- Center for Medicare and Medicaid Services IQIES - Internet Quality Improvement & Evaluation System

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 Outcome Assessment Information Set (OASIS) assessments to the Centers for Medicare and Medicaid Services (CMS) system, within 30 days of completing the OASIS assessment of the beneficiaries (patients). From 01/01/2023 thru 12/31/2023 1 of 4 OASIS assessments completed were transmitted greater than 30 days from the assessment date. This Failure prevented the agency's patient data from being made available to CMS for analysis in order to identify agency performance levels in the provision of patient care. Pre-survey review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 62116157 with 1 total record processed gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” During the entrance conference on 05/08/2024 at approximately 12:10 PM the surveyor and the Administrator discussed the OASIS reports. The surveyor asked who was responsible for transmitting the OASIS reports to CMS. The Administrator stated, “I do that” The surveyor asked what the agency process was for completing and submitting the OASIS to CMS. The Administrator stated, “I will review the OASIS and then I submit it to CMS.” The surveyor asked how often the agency submitted OASIS reports to CMS. The Administrator stated, “we don’t have patients so right now we don’t do any submission, but I know we have to submit them within 30 days of completion.” The surveyor reviewed the previously mentioned OASIS submission number 62116157 regarding Patient 9. The surveyor explained that the completed date (M0090) was 08/07/2023 and the submission date was 09/07/2023. The surveyor explained the OASIS was submitted more than 30 days after the completion date. The surveyor asked why the OASIS record was submitted more than 30 days past the completion date. The Administrator stated, “Oh, I don’t know. Let me try to find out. I don’t know.” On 5/13/2024 at approximately 10:45 AM the surveyor conducted an interview with the Administrator. The surveyor asked the Administrator if she found out why the OASIS mentioned previously was submitted late to CMS. The Administrator stated, “I don’t know it was missed I’m not sure why that was.” On 05/13/2024 at 11:14 AM, the surveyor reviewed the findings with the Administrator. The agency did not dispute the findings and did not provide any additional evidence to explain or correct the findings. Review of Agency policy titled, “TIMELINES IM.7” read in part: “II. All completed and encoded OASIS data… will be transmitted via electronic communication software… within thirty (30) days of the M0090 date.”