Every finding on record at Providian Healthcare Inc

A re-certification survey entrance conference was conducted on 12/10/2024 at 10:14 am. Census: L&C - 50 LHHS - 0 PAS – 0

A re-certification survey entrance conference was conducted on 12/10/2024 at 10:14 am. Census: L&C - 50 LHHS - 0 PAS – 0

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 transmit completed OASIS [ group of standard data HHAs integrate into their comprehensive assessment, to collect and report quality data to the CMS] assessments within 30 days of completion date for 12 of 12 months (October 2023 through September 2024) of transmissions reviewed. This failure prevented the patient's data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. Review of pre -survey report 12/9/2024, titled “HHA ERROR Summary by Agency” for reporting period 10/1/2023 to 09/30/2024 revealed that the agency had 100 (14.73%) out of 679 assessments had the error warning “-3330: Record Submitted late: The submission date was more than 30 days after M0090 [the assessment] on this record”. During an interview with the Alt Administrator on 12/12/2024 at 12:44 PM, when asked about the late OASIS assessment submissions, the alt adim stated she was the person in charge of the transmittals, but the alt DON was in charge of ensuring they were ready for transmittal on time. The alt DON had to send an email to the Alt Admin, along with verbal communication, when the OASIS documents were ready for transmission. The Alt Admin stated that since being in the position, she reviewed OASIS deadlines and reminded the DON and Alt DON of upcoming due dates. Surveyor requested and was provided a printout of the Oasis Error report for all submissions for October 2023 through September 2024. Review of the OASIS validation reports provided by the alt admin showed the Agency Error -3330 reports for October 2023 to September 2024 revealed there were 100 out of 679 OASIS assessments were transmitted late (more than 30 days after completion). During an interview on 12/12/2024 with the alt administrator and the DON, when asked why the assessments were being submitted late (more than 30 days from completion), the DON stated the OASIS Assessments were turned in by the nurses late, the nurses failed to complete the documentation in a timely manner even though it was indicated as due in the electronic documentation software. The surveyor asked if this information was brought to the attention of the administrative staff and nurses and what was the recommended solution. The admin stated she informed the staff and held meetings to address the issue. The Alt admin added that this had been identified as a problem via email and discussed during annual in-service training meetings in January, August, and November of 2024 and an extensive In-Service meeting was held in September of 2023 regarding the importance of Submitting OASIS in a timely manner. There was also a Board of directors meeting held in January of 2024 regarding what was required for OASIS. The DON and Alt DON continuously addressed the late assessments with the nurses and directed them to complete and turn in the OASIS assessments on time to avoid delayed transmissions. The Surveyor asked which staff were responsible for overseeing the timely completion/submission of the OASIS. The Administrator identified the Alt DON and the DON as the responsible parties. On 12/12/2024, review of the agency’s policy titled “IM.10 OASIS Collecting, Encoding and Transmitting Procedure” read in part: “……… B. The Agency must electronically report all OASIS data collected and update as required. C. §484.45(a) Encoding and transmitting OASIS data. 1.The Agency must encode and electronically transmit each completed OASIS assessment to the CMS system, for each beneficiary with respect to which information is required to be transmitted within 30 days of completing the assessment of the beneficiary. E.§484.45 (c) Transmittal of OASIS data. 1.An Agency must complete and successfully transmit OASIS data in a format that meets CMS requirements evident by validated reports.