Every finding on record at Sun City Home Care Inc

A recertification survey was conducted on 03/13/2025. The census was: L&CHHS: 109 PAS: 0 Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services PAS - Personal Assistance 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 was conducted on 03/13/2025. The census was: L&CHHS: 109 PAS: 0 Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services PAS - Personal Assistance 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 188 out of 1042 of the assessments processed for the time-period reviewed of 3/13/2024 to 3/13/2025. 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. Findings included: Review of the HHA Error Summary Report for the time-period of 3/13/2024 to 3/13/2025 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 188 assessments and the percentage of assessments with this error was 18.04% of assessments completed by the Agency. Review of the OASIS Error Detail Report for the time-period of 3/13/2024 to 3/13/2025 identified the 188 assessments with Error #-3330 as having submission dates of 3/18/2024, 3/21/2024, 8/21/2024, 8/23/2024, 9/11/2024, 9/25/2024, 11/03/2024, 11/12/2024, 11/20/2024, 12/05/2024, 12/19/2024, 1/16/2025, 1/21/2025, 2/22/2025, 3/5/2025 and 3/11/2025. An interview was conducted with the Alternate Administrator on 3/19/2025 at 9:57 AM, Surveyor reviewed the HHA Error Summary Report for the time-period of 3/13/2024 to 3/13/2025 with the Alternate Administrator. Surveyor asked the Alternate Administrator if they were aware of the amount of assessments being transmitted late and if the Agency had any practices in place to ensure assessments were submitted within the required time frame. The Alternate Administrator stated he was responsible for ensuring Outcome and Assessment Information Set assessments were submitted timely. The Alternate Administrator stated during a transition in Agency ownership, the Alternate Administrator was not able to access the Internet Quality Improvement and Evaluation System and was not able to transmit Outcome and Assessment Information Set assessments during this time. The Alternate Administrator provided documentation to this Surveyor which referenced the Alternate Administrator submitting tickets requesting assistance with his Internet Quality Improvement and Evaluation System account during the months of August and September in 2024 . The Alternate Administrator stated the Agency monitored and submitted Outcome and Assessment Information Set assessments on a weekly basis. During the exit conference on 03/19/2025 at approximately 12:10 PM, the findings were presented to the Administrator. No additional information was provided.