Every finding on record at Magnolia Home Health LLC

A recertification survey was conducted on 7/9/2025. The census was: L&CHHS: 0 LHHS: 0 Abbreviations/Acronyms: CMS: Centers for Medicare & Medicaid Services L&CHHS: Licensed and Certified Home Health Services LHHS: Licensed Home Health Services LVN: Licensed Vocational Nurse OASIS: Outcome and Assessment Information Set SN: Supervising Nurse The agency is in substantial compliance with no deficiencies cited.

A recertification survey was conducted on 7/9/2025. The census was: L&CHHS: 0 LHHS: 0 Abbreviations/Acronyms: CMS: Centers for Medicare & Medicaid Services L&CHHS: Licensed and Certified Home Health Services LHHS: Licensed Home Health Services LVN: Licensed Vocational Nurse OASIS: Outcome and Assessment Information Set SN: Supervising Nurse

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 10 out of 83 assessments processed for the time-period reviewed of 07/01/2024-07/01/2025. 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. In a review of the HHA Error Summary Report for the time period of 07/01/2024-07/01/2025, the report identified Error #-3330. The description for Error #-3300 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 10 assessments and the percentage of assessments with this error was 12.05% of assessments completed by the Agency. In an interview was completed with the Administrator on 7/09/2025 at 3:30 PM, the surveyor showed Administrator the “Home Health Error Summary” report which indicated that 10 OASIS assessments were late by the agency. The Surveyor asked the Administrator and Supervising Nurse who was responsible for submitting assessments to OASIS. The SN reported that she was, and the Administrator confirmed. The Surveyor asked what the agency's process was to ensure timely submissions of assessments. The SN stated that as part of their ongoing process to ensure timely submission, the agency had provided trainings on this and prioritized clear communication with the nurses. They also had devices in the field so they can submit the assessments while in the field. The Surveyor asked how late assessment submissions impacted client care. The Administrator and SN reported that they did not think it impacted client care, because the assessments were still being completed on time and the clients were still receiving all the care they needed, it was just an error with the data being transmitted on time. Review of the Agency’s policy titled “Timelines,” last reviewed 07/01/25, revealed a document that read in part, “All completed and encoded OASIS data will be transmitted via electronic communication 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 complies with the Federal Information Processing Standard (FIPS 140-2, issued May 25, 2001) from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date.”