Every finding on record at Sjc Home Health Care Inc

ABBREVIATIONS: ADM – Administrator ALT ADM – Alternate Administrator ALT SN – Alternate Supervising Nurse DON - Supervising Nurse / Director of Nursing HHA – Home Health Agency L&C - Licensed and Certified LHHS – Licensed Home Health Services PAS – Personal Assistance Services OASIS – Outcome and Assessment Information Set QAPI – Quality Assessment and Performance Improvement SN – Skilled Nurse TULIP – Texas Unified Licensure Information Portal. CFO - Chief Financial Officer A re-certification survey entrance conference was conducted on 11/15/2024 at 10:19am. Census: L&C - 29 LHHS - 1 PAS – 0 No deficiencies cited.

ABBREVIATIONS: ADM – Administrator ALT ADM – Alternate Administrator ALT SN – Alternate Supervising Nurse DON - Supervising Nurse / Director of Nursing HHA – Home Health Agency L&C - Licensed and Certified LHHS – Licensed Home Health Services PAS – Personal Assistance Services OASIS – Outcome and Assessment Information Set QAPI – Quality Assessment and Performance Improvement SN – Skilled Nurse TULIP – Texas Unified Licensure Information Portal. CFO - Chief Financial Officer A re-certification survey entrance conference was conducted on 11/15/2024 at 10:19am. Census: L&C - 29 LHHS - 1 PAS – 0 Abbreviations used:

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 in 12 of 12 (September 2023 through September 2024) months 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 11/12/2024, titled “HHA ERROR Summary by Agency” for reporting period 09/01/2023 to 09/30/2024 revealed that the agency had 15 (7.39) out of 203 number of assessments with error warning of “-3330: Record Submitted late: The submission date is more than 30 days after M0090 [ assessment] on this record”. On 11/15/2024 the administrator stated the billing department was changed in January of 2024 to resolve the OASIS transmittal issue. On 11/15/24 the agency Admin provided a printout of the Oasis Validation report of all submission for the 12-month period requested (September 2023 through September 2024). Review of the OASIS Agency Error -3330 reports in September 2023 revealed the due date of OASIS transmittals. (Submission were recorded to be late.) Reports for the OASIS Agency Final Validation report revealed submission date of 11/15/2024 with 203 submitted records which 15 records were with -3330 error code. During an interview on 11/15/2024 with the administrator and the OASIS Submitter the Surveyor ask why the assessments were not transmitted 30 days from completion. The admin stated she did not delay in submitting the report when it was completed but the error was mostly seen with OASIS Assessment and the nurses failure 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 what was the recommended solution. The admin stated she informed the staff, billing department, and hold held meetings to address the issue. In a continuous interview, the Administrator stated that she was aware about the OASIS late documentation past 30 days. The Administrator added that this had been identified as problems and in addition to annual in-service training, she had continuously reiterated with the nurses to complete and turned in the OASIS on time to avoid delay transmission. The Surveyor asked for the staff that were responsible for overseeing the timely completion/submission of the OASIS. The Administrator identified herself and the CFO as the responsible parties.