Every finding on record at Stn Home Health Services LLC

A recertification and re-licensure survey were conducted on 08/27/2024 at 2:30 PM. Census: Licensed and Certified- 2 Licensed Home Health- 21 Personal Assistance Services- 5 An exit conference was conducted on 08/30/2024 with Administrator and Alternate Administrator at 3:30 PM. The preliminary findings were discussed. The agency is in compliance with no deficiencies cited.

A recertification and re-licensure survey were conducted on 08/27/2024 at 2:30 PM. Census: Licensed and Certified- 2 Licensed Home Health- 21 Personal Assistance Services- 5 An exit conference was conducted on 08/30/2024 with Administrator and Alternate Administrator at 3:30 PM. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Acronyms used: CMS – Center for Medicare and Medicaid Services DON – Director of Nursing FIPS – Federal Information Process Standards HHA – Home Health Agency IM – Internal Memorandum IQIES - Internet Quality Improvement and Evaluation System LLC – Limited Liability Company M0090 – Official OASIS assessment form OASIS – Outcome and Assessment Information Set

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 electronically transmit completed OASIS assessments to the state agency within 30 days of completing OASIS assessments for 8 of 17 assessments processed from 08/28/2023-08/28/2024. This failure prevented the agency’s patient data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. The surveyor reviewed the OASIS Error Detail Report and HHA Error Summary by Agency for the agency in the IQIES portal on 08/28/2024, as part of the survey record review. The report documented eight patients whose OASIS assessments were submitted more than 30 days after the M0090 (the date of completion of the assessment). The time period of review was 08/28/2023-08/28/2024, the error rate was 47.06%, 17 assessments and 8 late submission errors. In an interview with the Alternate Administrator/DON on 08/28/2024 at 11:30 AM, the surveyor asked who in the agency was responsible for transmitting the OASIS assessments. The Alternate Administrator/DON stated it was the responsibility of the Alternate Administrator/DON to transmit the OASIS assessments. The surveyor asked the Alternate Administrator/DON how often she transmitted the OASIS reports. The Alternate Administrator/DON stated the OASIS reports were transmitted as soon as possible. The surveyor reviewed the information on the OASIS Error Detail Report and HHA Error Summary by Agency for the time period 08/28/2023-08/28/2024 with the Alternate Administrator/DON and asked about the late transmission of the assessments at a rate of 47.06% 8 out of 17 assessments. The Alternate Administrator/DON stated she was aware the (OASIS) assessments were transmitted late and she knew they were supposed to be transmitted within 30 days of the assessments. Review of agency policy, STN Home Health Services LLC, Clinical Policies and Procedures Not dated, quoted in part, “Policy 4.34: OASIS Data (encoding, Locking & Reporting) Page 1 of 2… POLICY The STN Home Health Services LLC uses software that meets federal specifications for the encoding, locking and reporting of OASIS data. The software accommodates data entry of OASIS items from all required time points. OASIS data items are encoded, checked for errors and locked within 7 days of collection and made transmission ready. PROCEDURE: in part - 4. All previous month client locked data is transmitted no later than the last day of each month (specifically every two-three week).