Every finding on record at New Concept Health Services Inc

A recertification and follow up (60409 and 4F58D) survey entrance conference was conducted on 4/11/25 at 1:40 pm with the Administrator and Alternate Administrator. Census: 109 License and Certified-3 Licensed Home Health-41 Personal Assistance Services 65 The agency has no deficiencies cited.

A recertification and follow up (60409 and 4F58D) survey entrance conference was conducted on 4/11/25 at 1:40 pm with the Administrator and Alternate Administrator. Census: 109 License and Certified-3 Licensed Home Health-41 Personal Assistance Services 65 Acronyms used: OASIS – Outcome and Assessment Information Set QAPI- Quality Assessment Performance Improvement IQIES – Internet Quality Improvement and Evaluation System CMS – Centers for Medicare and Medicaid Services EMR-Electronic Medical Records CASPER-Certification and Survey Provider Enhanced Reporting

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 did not code and electronically submit OASIS assessment data to IQIES (electronic system used to transmit quality measures) within 30 days for 5 of 8 patients reviewed. 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 ran on 4/11/25 dated 1/1/24 to 4/15/25 generated by the surveyor during pre-survey indicated the agency failed to code and electronically transmit OASIS assessment data to the CMS system within thirty days of completing the assessment of the beneficiary and indicated no data was available. Record review of an IQIES Error Summary Report ran on 4/18/25 dated 1/1/23 to 4/15/25 generated by the surveyor during the survey indicated the agency had not coded and electronically transmitted any OASIS assessment data to the CMS system within thirty days of completing the assessment of the beneficiary since 7/28/2023. Record review of an IQIES Home Health Agency (HHA) Report ran on 4/18/25 during the survey dated 7/28/23 to 4/18/25 indicated the agency had not reported to CMS any admitted patients between 7/28/23 to 4/18/2025. Review of the OASIS data report provided by the agency dated 4/15/25 indicated: Patient # 1 was recertified on 5/14/24, start of care on 8/5/24, and had been recertified on 10/2/24, 11/29/24, 1/28/25, and 3/28/25. Patient # 3 had been recertified on 5/15/24, 7/12/24, 9/12/24, 11/12/24, 1/8/25, and 3/11/25. Patient # 4 had been recertified on 5/14/24, 7/15/24, 9/13,24, 11/11,24, 1/10/25, had a resumption of care on 2/3/25, and was recertified on 3/10/25. Patient # 6 had been recertified on 5/10/24, 7/11/24, 9/6/24, and 11/8/24. Patient # 7 had a start of care on 5/10/24 and had been recertified on 7/4/24 and 9/4/24. The IQIES Error Summary Report did not show the agency had encoded and submitted the data from these OASIS to CMS. Review of a plan of care dated 11/9/24 to 1/7/25 indicated Patient #6 was admitted to the agency on 5/19/2023 for skilled nursing and physical therapy services. Diagnoses included Hypertension (high blood pressure) and chronic kidney disease (kidneys are unable to filter blood properly). Review of a plan of care dated 9/7/24 to 11/5/24 indicated Patient #7 was admitted to the agency on 5/10/24 for skilled nursing services. Diagnoses included Chronic Obstructive Pulmonary Disease (lung disease that causes difficulty breathing) and hypertension (high blood pressure). Review of a plan of care dated 4/2/25 to 5/31/25 indicated Patient #1 was admitted to the agency on 8/5/24 for skilled nursing services. Diagnoses included Type 2 diabetes (body does not use insulin properly) and hypertensive heart disease (heart problems caused by high blood pressure). Review of a plan of care dated 3/14/25 to 5/12/25 indicated Patient #3 was admitted to the agency on 2/3/21 for skilled nursing services. Diagnoses included Type 2 diabetes (body does not use insulin properly), foot ulcer (foot wound) and hypertension (high blood pressure). Review of a plan of care dated 3/15/25 to 5/13/25 indicated Patient #4 was admitted on 2/4/21 for skilled nursing services and physical therapy services. Diagnoses included Type 2 diabetes (body does not use insulin properly) and hypertensive heart disease (heart problems caused by high blood pressure). During an interview on 4/15/25 at 11:43 am the Alternate Administrator said OASIS data should be transmitted to IQIES but she would check with the Administrator. During an interview on 4/15/25 at 11:45 am the Administrator said OASIS data was sent to IQIES through the EMR program automatically. The Administrator said the QA Consultants prepares the QA report and identified her as (QA B ). During an interview on 4/16/25 at 12:30 the Alternate Administrator said there was no one in the office designated to encode and submit the OASIS data because they thought the EMR program automatically did it when they locked the OASIS assessment (closing the assessment so no more edits are made indicating it is complete). The Alternate Administrator said she did not know if the QA Consultants contract stated if they would encode and submit the OASIS data to IQIES. Review of the QA Consultant’s contract dated 4/12/2019 indicated the QA Consultants would perform quarterly OASIS analysis, perform current/past with outcome trends, perform a review and analysis of CASPER reports (a report enabling providers to track their performance on quality measures, to identify areas for improvement, and understand how their facility’s performance compares to others), comparison with home health compare and strategies for controlling outcomes via OASIS analysis. The contract did not read the QA Consultant would encode and transmit OASIS data. The contract identified QA B as the Project Manager. The contract was signed by a QA Consultant representative, but the signature was not legible and was also signed by the agency Administrator. During a telephone interview on 4/17/25 at 11:00 am QA C said she and QA B run the OASIS error summary report, they do not encode or transmit the OASIS data, the agency was responsible for that. QA C said she could not recall if there had been a discussion with anyone at the agency questioning why no data was showing up on the OASIS error summary report when the agency had Medicare/Medicaid patients on services. Attempts to call and interview an EMR representative on 4/16/25 at 12:45 pm and 4/17/25 at 10:00 am were made. There was no answer, surveyor left a voicemail for call back. No call back was received before exit. Review of an agency Administrative Policy dated 10/25/24, titled Timelines, indicated, “II. 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.”