Every finding on record at Luxur Health Services Inc

A recertification survey was conducted on 03/25/2025. The Agency census was: L&CHHS - 9 LHHS - 0 PAS - 21 Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services PAS - Personal Assistance Services CMS - Centers for Medicare & Medicaid Services OASIS - Outcome and Assessment Information Set iQIES - Internet Quality Improvement and Evaluation System HHA - Home Health Agency QAPI - Quality Assessment Performance Improvement

A recertification survey was conducted on 03/25/2025. The Agency census was: L&CHHS - 9 LHHS - 0 PAS - 21 Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services PAS - Personal Assistance Services CMS - Centers for Medicare & Medicaid Services OASIS - Outcome and Assessment Information Set iQIES - Internet Quality Improvement and Evaluation System HHA - Home Health Agency QAPI - Quality Assessment Performance Improvement

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 encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the patient for 3 out of 34 of the assessments processed for the time-period reviewed of 3/19/2024 to 3/19/2025. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare and improve patient care failing to be reported to CMS in the required time frame. Findings included: Review of the HHA Error Summary Report for the time-period of 3/19/2024 to 3/19/2025 identified Error #-3330. The description for Error #-3330 read in part, “Record Submitted Late: The submission date was more than 30 days after M0090 (item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with this error was 3 assessments and the percentage of assessments with this error was 8.82% of assessments completed by the Agency. Review of the Agency's QAPI binder revealed the Agency held a meeting regarding "OASIS exportation," dated 02/03/2025. The Agenda for the meeting read in part, 1. Discussion on late OASIS exportations 2. iQIES HHA Error Summary % of Late Submission/Exportation 3. Analyzation of the pulled-out report from iQIES for... (January-December 2024) 4. Identifying challenges within the clinical department 5. Implementation of solutions to prevent late OASIS exportation..." An interview was conducted with the Alternate Administrator/Supervising Nurse and the Office Manager on 03/26/2025 at 4:00 PM. Surveyor reviewed the HHA Error Summary Report for the time-period of 3/19/2024 to 3/19/2025 with the Alternate Administrator/Supervising Nurse and the Office Manager. The Alternate Administrator/Supervising Nurse stated that herself and the Office Manager are responsible for ensuring OASIS assessments are submitted timely and track this on a weekly basis. The Alternate Administrator/Supervising Nurse stated aside from the factors which contribute to late OASIS submissions mentioned in the 02/03/2025, the Agency has found that when an OASIS assessment is rejected due to an error, it is corrected and then by the time of re-submission, the OASIS assessment is late.