Every finding on record at Malou Home Health Inc

An Entrance Conference was conducted on 05/28/2024 with the Administrator, the Alternate Supervising Nurse, the Primary Home Care Coordinator, the Licensed Vocational Nurse and via telephone with the Alternate Administrator/Supervising Nurse at 9:45 AM. The Agency representatives were informed the purpose of the visit was a Recertification survey. Written information regarding "What to Expect During Your Agency's Survey" was provided. The Agency census was: L&CHHS - 16 LHHS - 0 PAS - 6 Hospice - 0 An Exit Conference was conducted on 05/30/2024 with the Alternate Administrator/Supervising Nurse, the Alternate Supervising Nurse, the Primary Home Care Coordinator, the Licensed Vocational Nurse and via telephone with the Administrator at 12:30 PM. The preliminary findings of the survey were reviewed. 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 Violations. 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

An Entrance Conference was conducted on 05/28/2024 with the Administrator, the Alternate Supervising Nurse, the Primary Home Care Coordinator, the Licensed Vocational Nurse and via telephone with the Alternate Administrator/Supervising Nurse at 9:45 AM. The Agency representatives were informed the purpose of the visit was a Recertification survey. Written information regarding "What to Expect During Your Agency's Survey" was provided. The Agency census was: L&CHHS - 16 LHHS - 0 PAS - 6 Hospice - 0 An Exit Conference was conducted on 05/30/2024 with the Alternate Administrator/Supervising Nurse, the Alternate Supervising Nurse, the Primary Home Care Coordinator, the Licensed Vocational Nurse and via telephone with the Administrator at 12:30 PM. The preliminary findings of the survey were reviewed. 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 Violations. 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

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 36 of 177 assessments processed for the time period reviewed of 05/12/2023 to 05/01/2024. 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 05/01/2024 was reviewed. Review of the HHA Error Summary Report for the time-period of 05/12/2023 to 05/01/2024 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 36 assessments and the percentage of assessments with this error was 20.34% of assessments completed by the Agency. An interview was conducted with the Alternate Administrator/Supervising Nurse on 05/30/2024 at 10:05 AM. The HHA Error Summary Report was reviewed with the Alternate Administrator/Supervising Nurse. The Alternate Administrator/Supervising Nurse stated the Agency was aware of the late submissions of OASIS assessments and was working on correcting the issue. The Alternate Administrator stated the Agency had payroll incentives for Agency nurses turning in documentation on time to improve timeliness of OASIS submissions. The Alternate Administrator/Supervising Nurse stated the Agency also frequently educated Agency nurses on timely submission of documentation. Review of the Agency's policy and procedure manual revealed a policy titled "OASIS Collecting, Encoding and Transmitting," dated 06/12/2020, which read in part, "The Agency must encode and electronically transmit each collected OASIS assessment to the CMS system, for each beneficiary with respect to which information is required to be transmitted within 30 days of completing the assessment of the beneficiary."