Every finding on record at M B Care LLC

An Entrance Conference was conducted on 07/01/2024 with the Office/Billing Department Representative, the Supervising Nurse and via telephone with the Administrator at 10:10 AM. The Agency representatives were informed the purpose of the survey was a Recertification Survey. Written information regarding "What to Expect During Your Agency's Survey" was provided. The Agency census was: L&CHHS - 94 An Exit Conference was conducted on 07/08/2024 with the Administrator, the Supervising Nurse and the Office/Billing Department Representative at 11:15 AM. 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/Acronyms: L&CHHS - Licensed and Certified Home Health Services CMS - Centers for Medicare & Medicaid Services OASIS - Outcome and Assessment Information Set iQIES - Internet Quality Improvement and Evaluation System HHA - Home Health Agency

An Entrance Conference was conducted on 07/01/2024 with the Office/Billing Department Representative, the Supervising Nurse and via telephone with the Administrator at 10:10 AM. The Agency representatives were informed the purpose of the survey was a Recertification Survey. Written information regarding "What to Expect During Your Agency's Survey" was provided. The Agency census was: L&CHHS - 94 An Exit Conference was conducted on 07/08/2024 with the Administrator, the Supervising Nurse, and the Office/Billing Department Representative at 11:15 AM. 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/Acronyms: L&CHHS - Licensed and Certified Home Health Services CMS - Centers for Medicare & Medicaid Services OASIS - Outcome and Assessment Information Set iQIES - Internet Quality Improvement and Evaluation System HHA - Home Health Agency

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 (A tool used by CMS to collect certain patient information) assessment to the CMS system, within 30 days of completing the assessment of the patient for 2 (Patient #7 and #8) of 363 assessments processed for the time-period reviewed of 05/12/2023 to 12/31/2023. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare failing to be reported to CMS in the required time frame. Findings included: The HHA Error Summary Report, retrieved from the iQIES website for the time-period of 05/12/2023 to 12/31/2023 was reviewed. Review of the HHA Error Summary Report for the time-period of 05/12/2023 to 12/31/2023 identified Error #-3330. The description for Error #-3330 read in part, “Record Submitted Late: The submission date is 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 2 assessments and the percentage of assessments with this error was 0.55% of assessments completed by the Agency. Review of the Agency’s QAPI Meeting Minutes for the years of 2022 and 2023 reviewed the Agency reviewed the HHA Error Summary Report for the time-period superseding the meeting at each quarterly meeting. An interview was conducted with the Administrator, the Office/Billing Representative and the Supervising Nurse on 07/08/2024 at 9:54 AM. The HHA Error Summary Report for the time-period of 05/12/2023 to 12/31/2023 was reviewed with the Administrator the Office/Billing Representative, and the Supervising Nurse. The Office/Billing Representative stated that she is responsible for ensuring OASIS assessments are encoded and transmitted in the time-period required and provided a log titled, “Submission Report,” where she tracked the submission of OASIS assessments. On 07/08/2024, at 10:27 AM, an interview was conducted with the Administrator and the Office/Billing Representative. The Office/Billing Representative stated the OASIS assessment was late for Patient #7 due to a glitch in the Clinical Record Software System that the Agency utilized. The Office/Billing Representative stated the Agency reached out to the Clinical Record Software System for assistance with the glitch and by the time they received a resolution, the OASIS assessment was going to be transmitted late. The Office/Billing Representative stated the OASIS assessment was showing up late for Patient #8 as the start of care date was corrected due to the Agency’s start of care date overlapping with the discharging Agency’s discharge date. Documentation provided by the Agency revealed a log titled, "Submission Report," not dated. The log revealed tracking of OASIS submissions by the Agency. The documentation also included a document titled, "OASIS Agency Final Validation," dated 08/11/2023. The document revealed the submission for Patient #7 with a message of “-3330 Warning…Records Submitted Late: The submission date is more than 30 days after M0090 (Item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation included a note documented by the Office/Billing Representative which read in part, “Late due to OASIS (ROC) issues with some wounds that were duplicated in the system. [Clinical Records Software System] was notified and worked on the issue.”