Every finding on record at Maranatha Home Health

Purpose -To conduct a re-licensure/recertification survey. On 09/09/25, the surveyor conducted an unannounced visit. The agency is in compliance with no violations cited. Census: L&CHHS – 2 LHHS – 482 PAS – 9 Abbreviations: Adm – Administrator L&CHHS- License and Certified Home Health Services LHHS – Licensed Home Health Services PAS – Personal Assistance Services

Purpose of Survey – To conduct a recertification Re-licensure survey. On 09/09/25, the surveyor conducted an unannounced visit. Census: L&CHHS –2 LHHS –482 PAS – 9 Abbreviations: L&CHHS- License and Certified Home Health Services LHHS – Licensed Home Health Services PAS – Personal Assistance Services Adm – Administrator L&CHHS- License and Certified Home Health Services LHHS – Licensed Home Health Services PAS – Personal Assistance Services CFR – Code of Federal Regulations OASIS- Outcome and Assessment Information Set IQIES - Internet Quality Improvement and Evaluation System CMS- Center For Medicare and Medicaid Services

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 interview and record review, the agency failed to code and electronically transmit each completed OASIS (data collected as part of the comprehensive assessment) assessment to the CMS system within thirty days of completing the assessment of the beneficiary for 12 of 49 (26.49%) records submitted[AE1] with dates reviewed 09/01/2024 – 09/01/2025 The agency did not code and electronically submit 12 patient’s OASIS data to IQIES (electronic system used to transmit quality measures from the OASIS data collected during comprehensive assessments) within 30 days to track and evaluate changes in the patient’s health while admitted to home health services to help ensure quality healthcare for patients. This failure prevented the agency’s patient OASIS data from being made available to CMS for analysis of patient care performance. The Failure Could put the Patient at risk for delayed care and treatment. Findings included: Record review of an iQIES Error Summary Report dated 09/08/25 indicated the agency failed to code and electronically transmit 12 out of 49 OASIS assessments data to the CMS system within thirty days of completing the assessment of the beneficiary. During an interview on 9/12/25 at 3:00 p.m., Alternate Administrator stated She was the one who was responsible for submitting OASIS assessment data after it was completed by the agency staff. Alternate Administrator said the OASIS data was required to be submitted within 30 days after the assessment was complete During an interview on 9/12/25 at 3:00 p.m., the Alternate Administrator said the agency identified the root cause of late OASIS submissions as: The agency nurses not submitting the OASIS assessment data in a timely manner. The Alternate Administrator said she was aware that there was an issue with the OASIS assessments being submitted within the 30-day window. Record review of an agency policy titled “Timelines” reviewed 08/01/20, indicated: · All completed and encoded OASIS data which accurately reflects the Patients/Clients status at the time of the assessment 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 from the agency contractor to the CMS collection site within 30 days of the M0090 date (In the OASIS assessment refers to the last date when all the Information used to complete the comprehensive assessment and determine OASIS coding was gathered by the assessing Clinician.) The agency did not dispute the surveyor's findings.