Every finding on record at Mi Pueblo Home Health Care LLC

Purpose -To conduct a re-licensure/recertification survey. On 12/10/25, the surveyor conducted an unannounced visit, No Violations cited Census: L&CHHS – 5 Abbreviations: Adm – Administrator L&CHHS- License and Certified Home Health Services

Purpose of Survey – To conduct a recertification Re-licensure survey. On 12/10/2025, the surveyor conducted an unannounced visit. Census: L&CHHS –5 Abbreviations: Admin – Administrator Alt Admin – Alternate Administrator L&CHHS- License and Certified Home Health 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 170 of 178 (95.51%) records submitted. The agency did not code and electronically submit 170 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 being 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. Findings included: Record review of an IQIES Error Summary Report dated 12/04/25 for dates 12/01/2024 – 12/01/2025 indicated the agency failed to code and electronically transmit 170 out of 178 OASIS assessments data to the CMS system within thirty days of completing the assessment of the beneficiary. During an interview on 12/10/25 at 4:00 p.m., Administrator stated that She was the one who was responsible for submitting OASIS assessment data after it was completed by the agency staff. Administrator said the OASIS data was required to be submitted within 30 days after the assessment was complete. During an interview on 12/10/25 at 4:00 p.m., the 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. She stated that there are only two employees who are trying to do everything, and they focus more on Direct patient care: not the administrative things]. The Administrator said she was aware that there was an issue with the OASIS assessments being submitted within the 30-day window. Surveyor asked how this could affect patient care, Administrator stated “I don’t think it does, we focus on patient care, it's just to of us and we make sure our patents are taken care of.” Record review of an agency policy titled “Timelines” reviewed 01/29/20, indicated: · Encoding and Locking OASIS data for the state will be completed within 7 days of the completion of the Comprehensive Assessment. · Completed, Encoded and Locked Oasis data will be transmitted within (30) days of the M0090 Date. The agency did not dispute the surveyor's findings.

Purpose of Visit – To conduct a Recertification Survey Entrance Date/Time - On 12/20/22 at 10:30 a.m., the surveyor conducted an unannounced visit and an entrance conference with the Administrator and Alternate Administrator. Census: Licensed and Certified: 16 An exit conference was conducted on 12/23/2022 at 09:00 a.m. with the Adm. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. The agency was in compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies. Administrator - Adm Alternate Administrator – Alt Adm PDA- Personal Digital Assistant

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it had on-hand, 2-way radios, as described in their EPRP for use as their alternate mode of communication in the event of telephone or power failure This failure has the potential to negatively impact the agency's active patients if the agency is unable to function and meet its communication needs during a disaster. Findings Include: Review of the agency's Emergency Preparedness Manual page 25, no revision date revealed in part: “11. MITIGATION OF THE ADMINISTRATOR… COMMUNICATION: If communication methods at an Agency site are interrupted, mobile communication systems, email-wireless PDA’s, short-wave radios, and e-mail relays may be source utilized by administrative staff.” Further review of the Emergency Preparedness Manual and Emergency Preparedness and Response Plan revealed the agency's Emergency Preparedness and Response Plan failed to describe alternate forms of communication or alert systems for telephone or power failure if the cell phone service was unavailable. During an interview on 12/22/22 at 02:30 p.m. with the Adm, the Surveyor asked to see the short-wave radios fully charged, docked and ready to go in the event of an emergency. Adm confirmed that the Agency did not have short-wave radios and therefore failed to describe an alternate form of communication in the event of an emergency in its Emergency Preparedness Plan. Administrator also informed surveyor that the Agency did not have PDAs, nor e-mail relays to serve as alternate modes of communication in the event of an emergency. Agency policy manual form titled “Emergency Preparedness Manual” revealed in part in page 17 no revision date: “Communication Plan: The Agency will develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated at least annually. The communication plan must include all of the following: Contact information for: Primary and alternate means for communicating with agency staff, Federal, State, tribal, regional, and local emergency management agencies.”

Purpose of Visit – To conduct a Recertification Survey Entrance Date/Time - On 12/20/22 at 10:30 a.m., the surveyor conducted an unannounced visit and an entrance conference with the Administrator and Alternate Administrator. Census: Licensed and Certified: 16 An exit conference was conducted on 12/23/2022 at 09:00 a.m. with the Adm. The preliminary findings were discussed. The preliminary findings were discussed. 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. PDA- Personal Digital Assistant