Every finding on record at Toro Home Health Services Inc

Purpose: A recertification/ re-licensure/ complaint survey was entered on 11/19/2025. Census: L&C 5 LHHS 6 PAS 75 Intakes: 402788 The Agency was in compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Services Abbreviations: L&C—Licensed and Certified LHHS—Licensed by Health and Human Services PAS—Personal Attendant Services CFR—Code of Federal Regulations

Purpose: A recertification/ re-licensure/ complaint survey was entered on 11/19/2025. Census: L&C 5 LHHS 6 PAS 75 Intakes: 402788 Abbreviations: ADM—Administrator CMS—Centers for Medicare & Medicaid Services DON—Director of Nursing HCSSA— Home and Community Support Services Agencies IQIES—Internet Quality Improvement and Evaluation System L&C—Licensed and Certified LHHS—Licensed by Health and Human Services Medicaid—health coverage for low-income children, families, seniors, and people with disabilities Medicare—Government program for Health Insurance for people over 65 years old or older and younger people with disabilities PAS—Personal Attendant Services QAPI—Quality Assessment and Performance Improvement 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 transmit OASIS data for each completed OASIS assessment to the Centers for Medicare & Medicaid Services (CMS) system within 30 days of completing the assessment of the beneficiary for 32 of 32 OASIS assessments submitted from 10/01/24 to 9/30/25. Failure of the agency to transmit OASIS data within the required time frame prevented the agency’s patient data from being made available to CMS for analysis to evaluate the agency performance levels in the provision of patient care. Findings The surveyor reviewed the OASIS Error Detail Report for the agency in the IQIES portal on 11/17/2025, as part of the preparation for the survey. The report documented 32 late assessments transmitted from 10/01/2024 to 9/30/2025 were submitted more than 30 days after the M0090 (the date of completion of the assessment.) During the entrance conference on 11/19/2025 at 11:45 AM with the Administrator (ADM)/ Director of Nursing (DON) the surveyor noted the late submissions found during survey preparation and asked for OASIS final validation reports from 10/01/2024 to 9/30/2025. Record review of the QAPI program reveal an “Action Plan” dated 7/15/2024. The action plan revealed late submissions of OASIS and addressed the action taken to improve the process. The Administrator was to in-service skilled nurses regarding the completion of the OASIS in a timely manner so the agency could submit the OASIS within 30 days. According to the action plan “modification of the plan was “not necessary.” Documentation of the evaluation of the effectiveness of the action plan was not located in the QAPI records. The surveyor reviewed the OASIS Agency Final Validation (10/1/24 to 12/31/25) reports provided by the agency which documented the late OASIS submissions with the comment “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The report revealed 9 Oasis records had been submitted after 30 days. The surveyor reviewed the OASIS Agency Final Validation (10/16/25) reports provided by the agency which documented the late OASIS submissions with the comment “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” This report revealed 10 OASIS records submitted after 30 days. These 10 records included all adult patients who receive skilled care services. Texas Health and Human Services provided a “Long Term Care Regulation Provider Letter” (PL 19-22) dated 7/2/2025 to Home and Community Support Services Agencies (HCSSAs). This provider letter was updated to inform home health agencies (HHAs) of the Centers for Medicare & Medicaid Services (CMS) requirement, in accordance with the Code of Federal Regulations, Title 42, Chapter IV, Subchapter G, Part 4841, that beginning July 1, 2025, Medicare-certified HHAs must collect and report OASIS data on all adult patients, 18 years and older, who receive skilled care services, including those with non-Medicare and non-Medicaid payer sources, and those who self-pay. In a phone interview 11/25/2025 at 2:00 pm with the Administrator (ADM)/ DON, the surveyor asked about the process for OASIS. The ADM stated, “the initial assessment [OASIS] is completed within 48 hours. It [OASIS] is reviewed by Quality Assurance (QA) then it is sent to the doctor for signature. Once the doctor signs it [OASIS], I send it to CMS.” When asked who was responsible for transmitting the OASIS the ADM stated, “I am.” Surveyor asked if there could be any reasons the OASIS might be submitted late. The ADM stated, “if the nurse doesn’t turn it [OASIS] in within 48 hours or the doctor doesn’t sign the OASIS quickly.” The surveyor asked how late submission of the OASIS could affect the patients. The ADM stated, “the patient may not get the right care.” The agency had a policy titled: “Timeliness” (IM.10) revised dated 04/17/19. The policy read in part: “…Policy -Agency will ensure timely provision of service and services to meet the client's needs in compliance with all federal and state laws and Regulations. …Procedure: All Agency staff, and physician/physician office staff as appropriate, will be oriented to the following parameters: … A. 17. Encoding and transmission of OASIS data to CMS (Centers for Medicare and Medicaid) is performed at least monthly and prior to billing. The OASIS is required to be transmitted to CMS within thirty (30) days of the date the assessment is completed (M0090)…” The agency had a policy titled: “OASIS Collecting, Encoding, and Transmitting” (IM.11) revised dated 1/13/18. The policy read in part: “…Procedure: …C. Encoding and transmitting OASIS data. 1. The Agency must encode and electronically transmit each completed OASIS assessment to the CMS system, for each beneficiary with respect to which information is required to be transmitted within 30 days of completing the assessment of the beneficiary. …3. OASIS must be transmitted for all Medicare patients, Medicaid patients, and patients utilizing any federally funded health plan options that are part of the Medicare program (e.g., Medicare Advantage (MA) plans). OASIS must also be transmitted for all Medicaid patients receiving services under a waiver program receiving services subject to the Medicare Conditions of Participation. a. Submission of OASIS is required for all patients with payer source scored 1-4 in M0150. 4. Exceptions to the transmittal requirements are patients: a. Under age 18; b. Receiving maternity services; c. Receiving housekeeping or chore services only; d. Receiving only personal care services until further notice; and e. Patients for whom Medicare or Medicaid insurance is not billed…”