Every finding on record at Timecare Health Services, LLC

A relicensure and recertification survey was conducted on 8/21/2025. The census Murphy: 3 L&CHHS: 3 LHH: 0 PAS: 0 Abbreviation: HHA – Home Health Aide ANE – Abuse Neglect and Exploitation EMR – Employee Misconduct Registry NAR- Nurse Aide Registry L&CHHS – Licensed and Certified Home Health Services LHH – Licensed Home Health PAS – Personal Assistance Services OASIS – Outcome and Assessment Information Set RN - Registered Nurse There were no deficiencies cited.

A relicensure and recertification survey was conducted on 8/21/2025. The census Murphy: 3 L&CHHS: 3 LHH: 0 PAS: 0 Abbreviation: CMS – Center of Medicare and Medicaid HHA – Home Health Aide ANE – Abuse Neglect and Exploitation EMR – Employee Misconduct Registry NAR- Nurse Aide Registry L&CHHS – Licensed and Certified Home Health Services LHH – Licensed Home Health PAS – Personal Assistance Services OASIS – Outcome and Assessment Information Set RN - Registered Nurse

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 2 of 21 assessments processed for the time reviewed of 06/01/2024 to 12/31/2024. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare failing to be reported to CMS in the required time frame. The findings included: The HHA (Home Health Agency) Error Summary Report, retrieved from the iQIES website for the time of 06/01/2024 to 12/31/2024 was reviewed. Review of the HHA (Home Health Agency) Error Summary Report for the time-period 06/01/2024 to 12/31/2024 identified Error #-3330. The description for Error #-3330 read in part, “Record Submitted Late: The submission date is 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 the error were 2 assessments and the percentage of assessments with this error was 9.52% of the total of 21 assessments completed by the Agency. A joint interview was conducted with the Alternate Administrator and the Administrator on 8/26/2025 at 2:30 p.m. The HHA (Home Health Agency) Error Summary Report was reviewed with the Alternate Administrator. The Alternate Administrator stated the Agency both acknowledged the responsibility of the late submission. The Alternate Administrator also stated that the issue was with computer issues with transmitting with the CMS portal for OASIS submission. Record review of an agency policy titled, “Initial Assessment/Patient Assessment”, dated 1/29/2020, revealed, in part,” The agency will ensure safe, and accurate data collection and transmission of OASIS data is transmitted at least monthly…An RN…will complete the Initial Comprehensive Assessment that incorporates the OASIS data set, no later than five (5) calendar days after the start of care.”

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to administer proper written notice to 1 of 2 (Patient #5) discharged patients, in advance of the home health agency termination of on-going care in that: 1) The agency failed to administer Notice of Medicare Non-Coverage to Patient #5 prior to Patient #5’s discharge. This failure could place the agency's patients at risk due to inadequate continuation of care and patient preparation prior to patient discharge. The findings included: During the entrance conference on 8/21/2025 at 1:30 p.m., with the Administrator in person. With further discussion, the agency's administrative staff were notified that a recertification and relicensure survey would be conducted, and that discharged patients will be reviewed. The surveyor requested 2 discharged patient records for review. During a record review of Patient #5 clinical records, the clinical records reveal a start of care date of 10/17/2024 with a diagnosis of Thyroid (gland that stores hormones in the neck) disorders with a certification period of 10/17/2024-12/15/2024. Patient #5 was receiving skilled nursing visits once weekly and physical therapy twice weekly. Further review of clinical records reveal Patient #5 was discharged on 11/30/2024 due to change of insurance. Further record review revealed no evidence of the Notice of Medicare Non-Coverage was given to Patient #5. During an interview on 8/26/2025 at 2:30 p.m., with the Administrator, the Administrator was informed of the findings and acknowledged responsibility. The Administrator stated that at the time he didn’t think the Notice of Medicare Non-Coverage was needed because Patient #5 had a change of insurance but understands that the notice was necessary to provide Patient #5 an informed choice to continue non-covered services from the agency. Record review of an agency policy titled, “Patient Discharge", dated 12/11/2024, revealed, in part, ”Agency representatives will provide Notice of Medicare Non-Coverage to patients (or authorized representative) when providing 5-day notice of discharge… NOMNC may be delivered sooner than 2 days or the next to last visit before coverage ends….”