Every finding on record at Our Lady of Peace

A survey for compliance with CMS Appendix Z Emergency Preparedness Requirements, was conducted on 3/3/26-3/5/26, during a recertification survey. The facility is in compliance with the Appendix Z Emergency Preparedness Requirements.

On 3/3/26 to 3/5/26 a recertification survey was conducted. This resulted in a standard survey at Our Lady of Peace. The agency was found to have met not the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency's inability to ensure provision of quality of care. Unduplicated census previous 12 months: 36 Total Home Visits Conducted: 3 Hours of Operation: 8:00am -4:30pm Total number of Records Reviewed: 7

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 document review the agency failed to complete and electronically transmit Outcome and Assessment Information Set (OASIS) data set timely. This had the potential to affect all patients receiving services from the home health agency. Findings include: OASIS is a standardized set of data elements used by home health agencies to assess patient outcomes, support quality improvement, and report to CMS. According to CMS report titled HHA Error Summary by Agency report for dates 2/1/25 to 2/1/26 identified, “10.96% percentage of assessments with Error”. The OASIS Error Detail Report for dates 1/1/25 to 2/26/26 identified of the 10.96% errors, 40 submissions were identified with “Error, Record Submitted Late: the submission date is more than 30 days after M0090 on this new record”. During interview with director of hospice and home care (DH) on 3/5/36 at 11:48 a.m., DH reviewed the reports and stated expectation to have OASIS information submitted within 30 days per CMS guidelines. DH stated she was unaware of the error submissions and stated she “guessed” the reason for the error was because the organization had had a change in staff who were responsible for submitting the data.