Every finding on record at Tamcare Home Health Inc

A Recertification Survey was conducted on 05/21/2025. The Agency census was: L&CHHS - 34 Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services HHA - Home Health Agency OASIS - Outcome and Assessment Information Set CMS - Centers for Medicare Services QA – Quality Assurance

A Recertification Survey was conducted on 05/21/2025. The Agency census was: L&CHHS - 34 Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services HHA - Home Health Agency OASIS - Outcome and Assessment Information Set CMS - Centers for Medicare Services QA – Quality Assurance

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 (A tool used by CMS to collect certain patient information) assessment to the CMS system within 30 days of completing the assessment of the patient for 408 out of 748 of the assessments processed for the time-period reviewed of 5/21/2024 to 5/21/2025. 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 and had the potential to place patients at risk of substandard care. Findings included: Review of the HHA Error Summary Report for the time-period of 5/21/2024 to 5/21/2025 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 408 assessments and the percentage of assessments with this error was 54.55% of assessments completed by the Agency. An interview was conducted with the Administrator/Supervising Nurse on 05/23/2025 at approximately 11:20 AM. Surveyor reviewed the HHA Error Summary Report for the time-period of 05/21/2024 to 05/21/2025 with the Administrator/Supervising Nurse. The Administrator/Supervising Nurse stated OASIS assessments were encoded and transmitted by the Agency’s corporate office. The Administrator/Supervising Nurse stated the process was an Agency nurse conducted and documented the OASIS assessment and the Agency’s corporate office QA department would review the OASIS assessment, then the assessment was submitted. The Administrator/Supervising Nurse stated that he had never experienced this process taking longer than 5-7 days. An additional interview was conducted with the Administrator/Supervising Nurse on 05/23/2025 at approximately 2:35 PM. The Administrator/Supervising Nurse stated that he had reached out to the corporate office and was told there was an issue which resulted in OASIS assessments for Medicare Advantage patients to not be submitted. The Administrator/Supervising Nurse stated the Agency became aware of this issue in 2024, and submitted OASIS assessments retroactively, going as far back as 2022. The Administrator/Supervising Nurse stated this issue only affected Medicare Advantage patients. Review of the Agency’s policy and procedure manual revealed a policy titled, “Timelines,” dated 10/25/2024, which read in part, “All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set and the CMS-assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with the Federal Information Processing Standard…from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date.”