Every finding on record at Med Global Home Health Care Inc

Purpose of visit: Recertification survey Entrance conference date: 11/06/2024 The census was - 57 Licensed and Certified patients – 20 No deficiencies were cited.

Purpose of visit: Recertification and a complaint investigation survey Entrance conference date: 11/06/2024 The census was - 57 Licensed and Certified patients – 20 Intake:363563 Abbreviations: Alt Adm - Alternate Administrator CMS - Centers for Medicare & Medicaid Services DON - Director of Nurses HHA – Home Health Agency IQIES - IQIES - Internet Quality Improvement and Evaluation System OASIS - Outcome and Assessment Information Set QAPI – Quality Assessment and Performance Improvement QA - Quality Assessment

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 electronically transmit completed OASIS (a standardized data set that measures the quality and outcomes of home health patients) assessments to the CMS system for all Medicare patients within 30 days of completing the OASIS assessment of the beneficiary (patients) for 25.42% (61 of 240) of assessments transmitted during 11/01/2023 – 11/06/2024. This failure prevented the agency’s patient data from being made available to CMS within 30 days of the OASIS completion dates for analysis to identify agency performance levels in the provision of patient care. Findings included: During pre-survey activity on 11/06/2024: The surveyor reviewed the agency OASIS report titled, “HHA Error Summary by Agency” from IQIES (an internet-based system that includes survey and certification functions) during the one-year of 11/01/2023 – 11/06/2024. The HHA Error Summary by Agency report included 61 of 240 OASIS assessments (25.42%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment. Record review of document labeled “Addendum to QAPI Action Plan” revealed: 1. 10/27/23 - 21.62% noncompliant, action: continue to monitor. 2. 01/26/24 – 24.29% noncompliant, action: continue to educate and monitor. 3. 04/30/24 – 17.65% noncompliant, action: continue to monitor. 4. 07/31/24 – 36.17% noncompliant, action: continue to monitor. An interview was conducted with the Alt Adm on 11/06/2024 2:45 p.m. The Alt Adm said she was responsible for OASIS assessment submission to the CMS system after the DON complete the OASIS assessment QA. An interview was conducted with the Alt Adm on 11/06/2024 at 2:50 p.m., the surveyor reviewed the error summary report which included 61 of 240 OASIS assessments submitted late. Alt Adm said she received OASIS assessments late from the RN who did the OASIS assessments which resulted in the agency not following its policy. The surveyor asked what tracking system agency had to ensure timely submission of assessments. The Alt Adm said it was an ongoing issue and it’s in the QAPI action plan. Agency Policy titled, "Timelines IM.35" with a revision date of 05/02/2024, read in part, “…Purpose To establish timely parameters for all medical record information… Procedure… II. All completed and encoded OASIS data will be transmitted… to the CMS collection site within 30 days of the M0090 date…”