Every finding on record at St Luke Home Health Services, LLC

*EMERGENCY PREPAREDNESS* Survey conducted on 05/12-05/15/2025 revealed the above facility meets all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.

* MCCOMB* The Medicare Recertification survey conducted 05/12-05/15/2025 revealed the above facility has met all Medicare Conditions of Participation for Home Health Agencies (HHA). However, Standard-level deficiencies were cited. ____________

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 staff interviews, policy and procedure review, and review of the facility report “HHA Error Summary by Agency”, the facility failed to encode and electronically transmit each completed Outcome and Assessment Information Set (OASIS) assessment within 30 days of completing the assessment of the beneficiary for 116 patients in the past 12 months: 04/30/2024-04/29/2025. Findings Include: An Interview with Director of Clinical Services on 05/14/2024 at 4:30 p.m. confirmed there is a dedicated person that submits OASIS data for all five branches. Review of the facility’s Internet Quality Improvement and Evaluation (iQIES) Report, “HHA Error Summary by Agency” for the report period of 04/30/2024-04/29/2025 revealed, for the past 12 months, Error -3330 for 116 patient assessments was submitted late within 30 days of completing the assessment of the beneficiary. Review of the facility’s policy, “Reporting of OASIS Information”, revised February 2024, confirmed” Policy: The Agency will report required data collected for the Outcome and Assessment Information Set (Oasis) items… Agency will electronically transmit completed, encoded and locked OASIS date for each completed OASIS assessment at least monthly to the System…”. During the Exit Conference on 05/15/2025 at 12:30 p.m. with Director of Clinical Services and Registered Nurse #1, survey findings were discussed, and no further documentation was submitted for review.