Every finding on record at R & H Home Care Inc

A Recertification Survey was conducted on 05/13/2025. The Agency census was: L&CHHS - 49 PAS - 0 Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services PAS - Personal Assistance Services QAPI - Quality Assessment Performance Improvement HHA - Home Health Agency OASIS - Outcome and Assessment Information Set CMS - Centers for Medicare Services

A Recertification Survey was conducted on 05/13/2025. The Agency census was: L&CHHS - 49 PAS - 0 Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services PAS - Personal Assistance Services QAPI - Quality Assessment Performance Improvement HHA - Home Health Agency OASIS - Outcome and Assessment Information Set CMS - Centers for Medicare 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 record review and interview, the Agency failed to encode and electronically transmit each completed OASIS (A tool used by CMS to collect certain patient information) assessment to the CMS system within 30 days of completing the assessment of the patient for 776 out of 1130 of the assessments processed for the time-period reviewed of 5/13/2024 to 5/13/2025. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare and improve patient care failing to be reported to CMS in the required time frame and has the potential to place clients at risk of substandard care. Findings included: Review of the HHA Error Summary Report for the time-period of 5/13/2024 to 5/13/2025 identified Error #-3330. The description for Error #-3330 read in part, “Record Submitted Late: The submission date was more than 30 days after M0090 (item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with this error was 776 assessments and the percentage of assessments with this error was 68.67% of assessments completed by the Agency. An interview was conducted with the Administrator and the Alternate Administrator/Supervising Nurse on 05/15/2025 at approximately 3:00 PM. Surveyor reviewed the HHA Error Summary Report for the time-period of 05/13/2024 to 05/13/2025 with the Administrator and the Alternate Administrator/Supervising Nurse. The Administrator and the Alternate Administrator/Supervising Nurse stated they were not aware of the issue regarding late submission of OASIS assessments. The Administrator stated she transmits OASIS assessments on a weekly basis. The Administrator and the Alternate Administrator/Supervising Nurse were asked what factors may contribute to the Agency’s late transmission of OASIS assessments. The Alternate Administrator/Supervising Nurse stated late documentation completed by nurses completing the assessments and difficulty finding registered nurses could be a factor. The Alternate Administrator/Supervising Nurse stated the Agency does monitor OASIS transmissions as part of their QAPI program but was not aware of the amount of the late OASIS submissions by the Agency. An additional interview was conducted with the Administrator on 05/16/2025 at approximately 3:10 PM. The Administrator stated that she was responsible for encoding and transmitting OASIS assessments. The Administrator stated that after we spoke about OASIS, she reviewed her transmission history and determined that some months she was transmitting regularly and some months she did not transmit at all. The Administrator stated the expectation is that the Administrator transmit OASIS assessments on a weekly basis.