Every finding on record at Standard Regional Home Health Inc

A recertification survey and intake investigation (#512501) were conducted on 01/28/25. The census was: L&CHHS: 73 Abbreviations/Acronyms: L&CHHS: Licensed and Certified Home Health Services CMS: Centers for Medicare & Medicaid Services OASIS: Outcome and Assessment Information Set iQIES: Internet Quality Improvement and Evaluation System HHA: Home Health Agency

A recertification survey and intake investigation (#512501) were conducted on 01/28/25. The census was: L&CHHS: 73 Abbreviations/Acronyms: L&CHHS: Licensed and Certified Home Health Services CMS: Centers for Medicare & Medicaid Services OASIS: Outcome and Assessment Information Set iQIES: Internet Quality Improvement and Evaluation System HHA: Home Health Agency

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 assessment to the CMS system within 30 days of completing the assessment of the patient for 6 assessments processed for the time-period reviewed of 1/27/2024 to 1/27/2025. 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. Findings included: The HHA Error Summary Report, retrieved from the iQIES website for the time period of 1/27/2024 to 1/27/2025 was reviewed. Review of the HHA Error Summary Report for the time period of 1/27/2024 to 1/27/2025 identified Error #-3330. The description for Error #-3300 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 6 assessments and the percentage of assessments with this error was 0.65% of assessments completed by the Agency. An interview was completed with the Administrator and Supervising Nurse on 2/3/2025 at 1:5 PM. The HHA Error Summary Report for the time of 1/27/2024 to 1/27/2025 was reviewed with the Administrator and Supervising Nurse. The Surveyor asked about the process for submitting OASIS assessments. The Supervising Nurse reported that the clinician completes the assessment and then there was a QA process. The Supervising Nurse reported that this all normally was very quick and occurred within 5 days and was then submitted. The surveyor asked if they were able to identify a reason for why submissions would be late. The Supervising Nurse reported that if something was late then likely would have been due to a delayed face to face encounter with the patient’s provider. The surveyor asked if they had done anything to prevent delays in submitting to OASIS. The Supervising Nurse responded that they had not made any changes. The surveyor asked how this affected client care. The Supervising Nurse responded that she felt like it did not impact client care, and that it was more of a behind the scenes technical issue. The Administrator reported that he did not have anything additional to add. Review of the Agency’s policy titled “Medical Record Information Timelines,” dated 11/27/20, revealed that all completed and encoded OASIS data would be submitted within 30 days of the assessment date.