Purpose of Visit: To conduct a Re-certification. On 02/18/25 at 2:08 p.m., the Surveyor conducted an unannounced visit, and an entrance conference was conducted. Census: Licensed & Certified- 84 Total: 84 Adm- Administrator CFR- Code of Federal Regulations DON-Director of Nurses LVN-Licensed Vocational Nurse QA- Quality Assurance The agency was in substantial compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies.
Every finding on record at Torres Home Health Services, Lc
Laredo, Texas · CCN 679490
5 findings across 1 survey, in the inspector's own words.
The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.
Survey of February 27, 2025
5 findingsPurpose of Visit: To conduct a re-certification and follow-up survey On 02/18/25 at 2:08 p.m., the Surveyor conducted an unannounced visit, and an entrance conference was conducted. Licensed & Certified- 84 Total: 84 Adm- Administrator a.m.- ante meridiem (before midday) CMS- Center for Medicaid and Medicare Services DON- Director of Nurses LVN- Licensed Vocational Nurse MAR- Medication Administration Record M0090- date an assessment was conducted OASIS- Outcome and Assessment Information Set QA- Quality Assurance SN- Skilled 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 transmit completed OASIS assessments within 30 days of completion date from February 10,2025 to August 04, 2024, of transmissions reviewed as followed: 1. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 12/31/24 for Patient #8. 2. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 01/09/25 for Patient #9. 3. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 01/05/25 for Patient #10. 4. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 12/31/24 for Patient 11. 5. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/27/24 for Patient #6. 6. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 12/11/24 for Patient #12. 7. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 12/20/24 for Patient #13. 8. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/27/24 and 11/25/24 for Patient #14. 9. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/25/24 for Patient #15. 10. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/07/24 for Patient #16 11. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date 12/12/24 for Patient #17. 12. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 12/10/24 for Patient #18. 13. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/19/24 for Patient #19. 14. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/13/24 Patient #20 15. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/05/24 for Patient #21. 16. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/06/24 for Patient #22. 17. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 01/23/24 for Patient #23. 18. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/04/24 for Patient #24. 19. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 04/09/24 for Patient #25. 20. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/28/24 for Patient #1. 21. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/05/24 for Patient #1. 22. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/27/24 for Patient # 26. 23. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/30/24 for Patient #27. 24. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/20/24 for Patient #28. 25. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/17/24 for Patient #5 and Patient # 29. 26. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/05/24 for Patient #30. 27. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/19/25 for Patient #31. 28. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/18/24 for Patients#32. 29. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/23/23 for Patient #33. 30. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 12/01/23 for Patient #33. 31 The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 01/31/24 for Patient #33. 32. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 03/03/24 for Patient #33. 33. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/17/24 for Patient #34. 34. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/30/24 for Patient #35. 35. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/10/24 for Patient #10. 36. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/11/24 for Patient #36. 37. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/01/24 for Patient #37. 38. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/05/24 for Patient #38. 39. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/30/24 for Patient #39. 40. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/11/24 for Patient #40. 41. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/11/24 for Patient #41. 42. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/30/24 for Patient #42. 43 The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/18/24 for Patient #43. 44. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/09/24 for Patient #44. 45. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/10/24 for Patient #45. 46. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/25/24 for Patient #46 and Patient #33. 47. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/16/24 for Patient #33. 48. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/16//24 for Patient #47. 49. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/06/24 for Patient #33. 50. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/09/24 for Patient #33. 51. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/29/24 for Patient #33. 52. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/20/24 for Patient #48. 53. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 03/31/24 for Patient #33. 54. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/03/24 for Patient #49. 55. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/06/24 for Patient #50. 56. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/15/24 for Patient #51 and Patient#52. 57. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/24/24 for Patient #53. 58. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/22/24 for Patient #54. 59. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/09/24 for Patient #1. 60. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/16/24 for Patient #55. 61. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/06/24 for Patient #56. 62. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/28/24 for Patient #1. 63. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/30/24 for Patient #57. 64. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/11/24 for Patient #58 65. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/05/24 for Patient #58. 66. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/18/24 for Patient #59. 67. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/30/24 for Patient # 35. 68. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 04/30/24 for Patient #59. 69. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/22/24 for Patient #60. 70. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/15/24 for Patient #22. 71. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/20/24 for Patient #59. 72. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 04/30/24 for Patient #59. 73. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/22/24 for Patient #60. 74. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/15/24 for Patient #22. 75. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/20/24 for Patient #59. 76. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/20/24 for Patient #61. 77. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/21/24 for Patient #62. 78. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/11/24 for Patient #63. 79. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/29/24 for Patient #64. 80. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/05/24 for Patient #4. 81. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/09/24 for Patient #1 x2. 82. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/30/24 for Patient #27. 83. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/06/24 for Patient #65. 84. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/24/24 for Patient #66. 85. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/04/24 for Patient #67 and Patient #68. 86. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/23/24 for Patient #67. 87. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/12/24 for Patient #36. 88. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/27/24 for Patient #69. 89. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/31/24 for Patient #70. 90. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/21/24 for Patient #71. 91. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/02/24 for Patient #72. 92. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/18/24 for Patient #47 and Patient #73. 93. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/18/24 for Patient #74. 94. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/26/24 for Patient #75 and Patient # 39. 95. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/12/24 for Patient #76. 96. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/27/24 for Patient #54. 97. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/25/24 for Patient #77. 98. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/20/24 for Patient #46. 99. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/17/24 for Patient #78. 100. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/22/24 for Patient #79. 101. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/18/24 for Patient #61. 102. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/18/24 for Patient #80. 103. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/28/24 for Patient #38. 104. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/22/24 for Patient #79 105. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/07/24 for Patient #38. 106. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/03/24 for Patient #47. 107. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/02/24 for Patient #81. 108. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/03/24 for Patient #82 and Patient # 63. 109. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/04/24 for Patient #83. 110. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/12/24 for Patient #84. 111. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/11/24 for Patient # 85. 112. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/08/24/23 for Patient #1. 113. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/21/24 for Patient #86. 114. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 03/03/2424 for Patient #87. 115. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/07/24 for Patient #95. 116. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/18/24 for Patient #88 and Patient #89. 117 The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/18/24 for Patient #90. 118. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/30124 for Patient #91. 119. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/23/24 for Patient #92 120. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 03/28/24 for Patient #91. 121. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/03/24 for Patient #24. 122. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/29/24 for Patient #8. 123. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/06/24 for Patient #58 and for Patient #93. 124. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/06/24 for Patient #94. 125. The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/24/24 for Patient #95. Failure of the agency to transmit OASIS data within the required time frame of 30 days prevented the patient's data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. This failure had the potential to affect the agency's future patients for which OASIS were to be transmitted. The Findings Included: 1.Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time:02/10/25 15 :01:23. Continued review of this form revealed Patient #8’s M0090 Date (date an assessment was conducted) as 12/31/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 12/31/24 for Patient #8. 2. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 02/10/25 11:18:24 Continued review of this form revealed Patient #9’s M0090 Date as 01/09/25. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 01/09/25 for Patient #9. 3. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time:02/10/25 10:56:46. Continued review of this form revealed Patient #10’s M0090 Date as 01/05/25. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 01/05/25 for Patient #10. 4. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time:02/06/25 14:03:26. Continued review of this form revealed Patient #11’s M0090 Date as 12/31/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 12/31/24 for Patient #11. 5. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time:01/31/25 14:16:09. Continued review of this form revealed Patient #6’s M000 Date as 11/27/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/27/24 for Patient #6. 6. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time:01/27/25 18:46:32 Continued review of this form revealed Patient #12’s M0090 Date as 12/11/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 12/11/24. 7. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time:01/23/25 17:56:22. Continued review of this form revealed Patient #13’s M0090 Date as 12/20/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 12/20/24 for Patient #13. 8. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time:01/21/25 15:20:56 and on 1/21/25 18:08:20. Continued review of this form revealed Patient #14’s M0090 Date as date of 11/27/24 and 11/25/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/27/24 and 11/25/24 for Patient #14. 9. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time:01/20/25 00:09:34. Continued review of this form revealed Patient #15’s M0090 Date as 11/25/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/25/24. 10. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 01/16/25 16:35:01. Continued review of this form revealed Patient #16’s M0090 Date as 11/07/24 Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/07/24. 11. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 01/16/25 16:35:01. Continued review of this form revealed Patient #16’s M0090 Date as 11/07/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date 11/07/24. 12. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 01/14/25 18:16:44. Continued review of this form revealed Patient #17’s M0090 Date as 12/12/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 12/12/24 for Patient #17. 13. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 01/10/25 16:10:24. Continued review of this form revealed Patient #18’s M0090 Date as 12/10/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 12/10/24 for Patient #18. 14. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 01/07/25 14:11:14. Continued review of this form revealed Patient #19’s M0090 Date as 11/19/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/19/24. 15. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 01/03/25 16:52:14. Continued review of this form revealed Patient #20’s M0090 Date as 11/13/24, Patient #21’s M0090 Date as 11/05/24, Patient #22’s M0090 Date as 11/06/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on the record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/13/24 for Patient #20, MOO90 date of 11/13/24 for Patient #21, and M0090 date of 11/06/24 for Patient #22. 16. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 01/02/25 17:58:29. Continued review of this form revealed Patient #23’s M0090 Date as 01/23/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on the record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 01/23/24 for Patient #23. During an interview and record review on 02/26/25 between 3:42 p.m. and 13:47 with the Adm/DON and QA/LVN J the surveyor presented the above findings. The Surveyor asked who was responsible for submitting the OASIS once they were completed. Adm/DON stated, “QA/LVN J.” The Surveyor then asked what the agency’s policy was regarding submissions of the OASIS. Adm/DON stated, “30 days.” The Surveyor asked if the completed OASIS were submitted within 30 days. QA/LVN stated, “no.” The Surveyor then asked what the reason was the OASIS noted above were not submitted within the 30 days. QA/LVN J stated that she was having some issues with Axxess. The Surveyor then asked what the consequences would be if the OASIS is not submitted within the 30 days. QA/LVN J stated, not being on time with palmetto and it also affects billing.” 17. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 08/04/24 19:37:03. Continued review of this form revealed Patient #24’s M0090 Date as 07/04/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/04/24 for Patient #24. 18. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 08/07/24 12:07:53. Continued review of this form revealed Patient 25’s M0090 Date as 04/09/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 04/09/24 for Patient #25. 19. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 08/09/24 14:30:19. Continued review of this form revealed Patient #1’s M0090 Date as 05/28/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/28/24 for Patient #1. 20. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 08/09/24 14:36:13. Continued review of this form revealed Patient #1’s M0090 Date as 06/05/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/05/24 for Patient #1. 21. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 08/14/24 17:11:07. Continued review of this form revealed Patient #26 M0090 Date as 06/27/24 and M0090 date of 05/30/24 for Patient #27. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/27/24 for Patient #26 and M0090 date of 05/30/24 for Patient #27. 22. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 08/21/24 18:03:15. Continued review of this form revealed Patient #28’s M0090 Date as 07/20/24, Patient # 5’s MOO90 Date as 07/17/24, Patient # 29’s M0090 Date as 07/17/24, Patient # 30’s M0090 Date as 06/05/24, Patient # 31’s M0090 Date as 07/19/24, Patient # 32’s M0090 Date as 07/18/24, Patient # 33’s M0090 Date as 11/23/23, 12/01/23, 01/31/24, 03/03/24, Patient # 34’s M0090 Date as 07/17/24, and Patient # 35’s M0090 Date as 05/30/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion of M0090 Date as 07/20/24 for Patient #28, M0090 Date as 07/17/24 for Patient # 5, M0090 Date as 07/17/24 for Patient # 29, M0090 Date as 06/05/24 for Patient # 30, M0090 Date as 07/19/24 for Patient # 31, M0090 Date as 07/18/24 for Patient # 32, M0090 Date as 11/23/23, 12/01/23, 01/31/24, 03/03/24 for Patient # 33, M0090 Date as 07/17/24 Patient # 34, and M0090 Date as 05/30/24 for Patient # 35’s . 23. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 08/23/24 18:34:56. Continued review of this form revealed Patient #10’s M0090 Date as 07/10/24 and Patient #36’s M0090 Date as 07/11/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/10/24 for Patient #10 and M0090 Date of 07/11/24 for Patient 36. 24. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 08/29/24 16:57:39. Continued review of this form revealed Patient #37’s M0090 Date as 05/01/24 and Patient #38’s M0090 Date as 07/05/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/01/24 for Patient #37and 04/29/24 for Patient #38. 25. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 08/30/24 17:36:02. Continued review of this form revealed Patient #39’s M0090 Date as 07/30/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/30/24 for Patient #39. 26. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 09/03/24 11:02:41. Continued review of this form revealed Patient #40’s M0090 Date as 07/11/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/11/24 for Patient #40. 27. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 09/03/24 11:14:26. Continued review of this form revealed Patient #41’s M0090 Date as 06/11/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/11/24 for Patient #41. 28. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 09/03/24 11:32:55. Continued review of this form revealed Patient #42’s M0090 Date as 06/30/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/30/24 for Patient #42. 29. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 09/09/24 17:06:02. Continued review of this form revealed Patient #42’s M0090 Date as 04/11/24, Patient #43’s M0090 Date as 07/18/24, and Patient #44’s M0090 Date as 08/09/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 04/11/24 for Patient # 42, M0090 Date of 07/18/24 for Patient #43, and M0090 Date as 08/09/24 for Patient #44. 30. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 09/11/24 17:30:46. Continued review of this form revealed Patient #45’s M0090 Date as 05/10/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/10/24 for Patient #45. 31. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 09/18/24 17:46:13. Continued review of this form revealed Patient #46’s M0090 Date as 07/25/24, Patient #33’s M0090 Date as 07/25/24 and 08/16/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 07/25/24 for Patient #46, M0090 date of 07/25/24 and 08/16/24 for Patient #33. 32. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 09/19/24 17:27:30. Continued review of this form revealed Patient #47’s M0090 date of 08/16/24, and Patient #33’s M0090 date of 05/06/24, 05/09/24, and 05/29/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/16/24 for Patient #46 and 05/06/24, 05/09/24, and 05/29/24 for Patient #33. 33. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 09/23/24 15:59:48. Continued review of this form revealed Patient #48’s M0090 Date as 06/20/24, Patient #33’s M0090 date of 03/31/24, Patient #49’s M0090 date of 05/03/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/20/24 for Patient #48, M0090 date of 03/31/24 for Patient #33 and M0090 date of 05/03/24 for Patient #49. 34. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time :09/25/24 18:21:14. Continued review of this form revealed Patient #50’s M0090 Date as 06/06/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/06/24 for Patient #50. 35. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 09/26/24 17:36:14. Continued review of this form revealed Patient #51’s M0090 Date as 08/15/24 and Patient #52’s M0090 Date as 08/15/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/15/24 for Patient #51 and Patient #52. 36. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 09/26/24 17:56:13. Continued review of this form revealed Patient #53’s M0090 Date as 08/24/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/24/24 for Patient #53. 37. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 09/30/24 16:19:45. Continued review of this form revealed Patient #54’s M0090 Date as 08/22/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/22/24 for Patient #54. 38. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/06/24 21:54:04. Continued review of this form revealed Patient #1’s M0090 Date as 08/09/24 and Patient #55’s M0090 Date as 08/16/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/09/24 for Patient #1 and M0090 date of 08/16/24 for Patient #55. 39. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/07/24 17:11:55. Continued review of this form revealed Patient #56’s M0090 Date as 09/06/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/06/24 for Patient #56. 40. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/07/24 18:23:29. Continued review of this form revealed Patient #1’s M0090 Date as 10/28/23, Patient #57’s M0090 Date as 11/30/23, and Patient #33’s M0090 Date as 03/09/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/28/23for Patient #1, M0090 Date as 11/30/23 for Patient #57, and M0090 Date as 03/09/24 for Patient #33. 41. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/07/24 20:48:40 Continued review of this form revealed Patient #58’s M0090 Date as 06/11/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/11/24 for Patient #58. 42. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/10/24 16:37:56. Continued review of this form revealed Patient #58’s M0090 Date as 08/08/24, 09/05/24, Patient #59’s M0090 Date as 06/18/24, and Patient #35’s M0090 Date as 08/30/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/08/24, 09/05/24 for Patient 58, M0090 Date as 06/18/24 for Patient #59 and M0090 Date as 08/30/24 for Patient #35. 43. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/11/24 15:48:36 Continued review of this form revealed Patient #59’s M0090 Date as 04/30/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 04/30/24 for Patient #59. 44. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/11/24 17:47:21 Continued review of this form revealed Patient #60’s M0090 Date as 08/22/24 and Patient #22’s M0090 Date as 07/15/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/22/24 for Patient #60 and M0090 Date as 07/15/24 for Patient #22. 45. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time:10:11:24 18:16:54 Continued review of this form revealed Patient #59’s M0090 Date as 06/20/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after MOO90 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/20/24 for Patient #59. 46. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/11/24 15:48:36. Continued review of this form revealed Patient #59’s M0090 Date as 04/30/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 04/30/24 for Patient #59. 47. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/11/14 17:47:21. Continued review of this form revealed Patient #60’s M0090 Date as 08/22/24 and Patient #22’s M0090 Date as 07/15/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/24/24 for Patient #60 and M0090 Date as 07/15/24 for Patient #22. 48. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/11/25 18:16:54. Continued review of this form revealed Patient #59’s M0090 Date as 06/20/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 06/20/24 for Patient #59. 49. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/14/24 16:54:48. Continued review of this form revealed Patient #61’s M0090 Date as 08/20/24, Patient #62’s M0090 Date as 08/21/24, and Patient #63’s M0090 Date as 09/11/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/20/24 for Patient #61, M0090 date of 08/21/24 for Patient #62 and M0090 date of 09/11/24 for Patient #63. 50. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/16/24 15:59:31. Continued review of this form revealed Patient #64’s M0090 Date as 08/29/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/2924 for Patient #64. 51. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/16/24 16:37:29 and 17:04:27 Continued review of this form revealed Patient #4’s M0090 Date as 05/05/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date 05/05/24 for Patient #4. 52. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/22/24 15:31:40. Continued review of this form revealed Patient #27’s M0090 Date as 08/30/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/30/24 for Patient #27. 53. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/27/24 22:20:04. Continued review of this form revealed Patient #65’s M0090 Date as 09/06/24, Patient #66’s M0090 Date as 09/24/24, Patient #67’s M0090 Date as 09/04/24, and Patient #68’s M0090 Date as 09/04/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/06/24 for Patient #65, the M0090 date of 09/04/24 for Patient #66, the M0090 date of 09/04/24 for Patient #67, and the M0090 date of 09/06/24 for Patient #68. 54. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/27/24 22:23:45. Continued review of this form revealed Patient #67’s M0090 Date as 09/23/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/23/24 for Patient #67. 55. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/28/24 16:10:26. Continued review of this form revealed Patient #36’s M0090 Date as 09/12/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on the record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/12/24 for Patient #36. 56. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 10/28/24 18:28:26. Continued review of this form revealed Patient #69’s M0090 Date as 09/27/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after MOO90 on the record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/27/24 for Patient #69. 57. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 11/01/24 17:57:27 Continued review of this form revealed Patient #70’s M0090 Date as 08/31/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/31/24 for Patient #70. 58. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 11/05/24 17:59:54. Continued review of this form revealed Patient #71’s M0090 Date as 05/21/24 and Patient #21’s M0090 Date as 10/02/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/21/24 for Patient #71. 59. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 11/07/24 11:27:17 Continued review of this form revealed Patient #47’s M0090 Date as 09/18/24, Patient #73’s M0090 Date as 09/18/24 and, Patient #74’s M0090 Date as 09/18/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/18/24 for Patient #47, M0090 date of 09/18/24 for Patient #73, and M0090 date of 09/18/24 for Patient #74. 60. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 11/07/24 17:48:40 Continued review of this form revealed Patient #75’s M0090 Date as 09/26/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/26/24 for Patient #75. 61. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 11/08/24 12:08:35. Continued review of this form revealed Patient #39’s M0090 Date as 09/26/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/26/24 for Patient #39. 62. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 11/12/24 11:12:39. Continued review of this form revealed Patient #76’s M0090 Date as 10/12/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/12/24 for Patient #76. 63. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 11/13/24 12:26:31. Continued review of this form revealed Patient #54’s M0090 Date as 09/27/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/27/24 for Patient #54. 64. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 11/17/24 21:22:17 Continued review of this form revealed Patient #77’s M0090 Date as 09/25/24 and Patient #46’s M0090 Date as 09/20/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 Date as 09/25/24 for Patient #77 and M0090 date of 09/20/24 for Patient #46. 65. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 11/17/24 22:44:45. Continued review of this form revealed Patient #78’s M0090 Date as 10/17/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/17/24 for Patient #78. 66. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 11/20/24 17:55:55. Continued review of this form revealed Patient #61’s M0090 Date as 10/18/24 and Patient #80’s M0090 Date as 09/18/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/18/24 for Patient #61 and M0090 date of 09/18/24 for Patient #80. 67. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 11/21/24 16:35:39. Continued review of this form revealed Patient #38’s M0090 Date as 09/28/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 09/28/24 for Patient #38. 68. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 11/22/24 18:32:51. Continued review of this form revealed Patient #79’s M0090 Date as 10/22/24 Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/22/24 for Patient #79. 69. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 11/25/24 00:28:44. Continued review of this form revealed Patient #47’s M0090 Date as 10/03/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/03/24 for Patient # 47. 70. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 11/25/24 16:48:36. Continued review of this form revealed Patient #81’s M0090 Date as 10/01/24, Patient #82’s M0090 Date as 10/03/24, Patient #83’s M0090 Date as 10/04/24 and Patient #63’s M0090 Date as 10/03/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/01/24 for Patient #81, M0090 date of 10/03/24 for Patient #82, M0090 date of 10/04/24 for Patient #83, and M0090 date of 10/03/24 for Patient #63. 71. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 11/27/24 18:36:56, Continued review of this form revealed Patient #84’s M0090 Date as 10/12/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/12/24 for Patient #84. 72. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 12/02/24 00:06:03. Continued review of this form revealed Patient #85’s M0090 date of 10/11/24, M0090 date of 10/08/24 for Patient #1, and M0090 date of 05/21/24 for Patient #86. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 03/28/24, 03/28/24, and 03/27/24 for Patient #18, #45, and #46. 73. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 12/05/25 15:08:50. Continued review of this form revealed Patient #87 M0090 Date as 08/27/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 08/27/24 for Patient #87. 74. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 12/08/24 22:22:02. Continued review of this form revealed Patient #88’s M0090 Date as 10/18/24 and Patient #89’s M0090 Date as 10/18/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/18/24 for Patient #88 and M0090 date of 10/18/24 for Patient #89. 75. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 12/09/24 12:55:11 Continued review of this form revealed Patient #90’s M0090 Date as 10/18/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/18/24 for Patient #90. 76. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 12/10/24 11:56:04. Continued review of this form revealed Patient #91’s M0090 Date as 05/31/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 05/31/24 for Patient #91. 77. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 12/11/24 13:25:52. Continued review of this form revealed Patient #92’s M0090 Date as 10/23/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/23/24 for Patient #92. 78. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 12/10/24 12:10:02 Continued review of this form revealed Patient #91’s M0090 Date as 03/28/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 03/28/24 for Patient #91. 79. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 12/18/24 12:34:06. Continued review of this form revealed Patient #24’s M0090 Date as 10/03/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/03/24 for Patient #24. 80. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 12/19/24 17:21:05. Continued review of this form revealed Patient #8’s M0090 Date as 10/29/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 10/29/24 for Patient #8. 81. Review of the OASIS Validation Reports revealed a form titled, “OASIS Agency Final Validation” that included the Submission Date/Time: 12/30/24 12:53:55 Continued review of this form revealed Patient #58’s M0090 Date as 11/06/24, Patient #93 M0090 Date as 11/05/24, Patient #94’s M0090 Date as 11/05/24, and Patient #95’s M0090 Date as 10/24/24. Further review of this form revealed the following Message Number/ Severity that read in part: “ -3330 warning. Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” The agency failed to submit the OASIS assessments within 30 days of completion with the M0090 date of 11/06/24 for Patient #58, M0090 date of 11/05/24 for Patient #93, M0090 date of 11/05/24 for Patient #94, and M0090 date of 10/24/24 for Patient #95. During an interview and record review on 02/26/25 at 3:50 p.m. with the Adm/DON and QA/LVN J the surveyor presented the above findings. The Surveyor asked who was responsible for submitting the OASIS once they were completed. Adm/DON stated, “QA/LVN J.” The Surveyor then asked what the agency’s policy was regarding submissions of the OASIS. Adm/DON stated, “30 days.” The Surveyor asked if the completed OASIS were submitted within 30 days. QA/LVN stated, “No.” The Surveyor then asked what the reason was the OASIS noted above were not submitted within the 30 days. QA/LVN J stated that she was having some issues with Software BB. The Surveyor then asked what the consequences would be if the OASIS is not submitted within the 30 days. QA/LVN J stated, not being on time with Insurer BB and it also affects billing.” Review of the agency's policy manual revealed a policy titled "Timelines" IM. 35 with a reviewed date of 10/25/24. The policy revealed in part: … "II. 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 included 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 (FIPS 140-2, issued May 25, 2001) from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date.
Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to enforce its written policy when receiving verbal orders for 2 of 5 Active Patients (#1 and #3) whose records were reviewed in that: 1. LVN D did not submit an MD order regarding Patient #1’s family requesting the Left plantar 1st toe and Left dorsum 2nd toe to be covered with a dry dressing and secured with tape. 2. LVN H did not submit an MD order to continue previously ordered wound care to the left lower leg for Patient #3 due to lidocaine not available until 01/19/25. This failure could place the agency's patients at risk of not receiving the ordered care and services. The Findings Included: 1. Review of Patient #1’s electronic record revealed a form titled, “OASIS-E Recertification” that was signed and dated by RN G on 12/06/24 that read in part, … “Visit Interventions: … SN performed wound care orders as per wound care orders dated 11/29/24 as followed: … Wound location: Diabetic, left plantar 1st digit (hallux) and left dorsum 2nd digit (toe) Cleansed wound with saline or wound cleanser, patted dry with 4x4’s, painted wound bed with betadine and left open to air. Review of Patient # 1’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the Certification Period of 12/07/24 to 02/04/25 with a primary diagnosis of Pressure ulcer (wound that occurs on the feet, elbows caused by constant pressure) of left heel, stage 3 (a wound opening that exposes the fatty layer of skin). Review of Patient #1’s electronic record revealed SN notes that were signed and dated by LVN D on 12/18/24, 12/20/24, 12/23/24, and 12/25/24 that revealed the Left plantar 1st toe and Left dorsum 2nd toe to be covered with a dry dressing and secured with tape. Further review of Patient #1’s electronic record failed to reveal documentation of on an MD order regarding the Left plantar 1st toe and Left dorsum 2nd toe to be covered with a dry dressing and secured with tape. During an interview and record review on 02/27/25 at 10:41 a.m. with the Adm/ DON (present) and LVD D on conference call, the surveyor presented the above findings. The Surveyor asked if there was an order for the left plantar 1st digit (hallux) and left dorsum 2nd digit (toe) to be covered with dry dressing and to be secured with tape. LVN D stated, “the family requested (to cover the wounds) MD office was notified, I spoke with Staff X, and she said it was ok.” The Surveyor then asked if there was any reason for not submitting an MD order. LVN D stated, “I just forgot.” The Surveyor then asked what the consequences would be if the wound care was not followed. LVN D stated, “due to the dressing not much. Dr. might get upset.” 2. Review of Patient # 3’s electronic record revealed a form titled, “Home Health Certification and Plan Of Care” for the Certification Period of 01/05/25 to 03/05/25 with a primary diagnosis Chronic venous hypertension with ulcer of left lower extremity (a condition that occurs due to the veins in the legs not being able to pump blood back to the heart causing blood to stay in the lower legs causing wounds). Continued review of Patient #3’s electronic record revealed a form titled, “Physician Order” that was signed and dated by Adm/DON on 01/29/25 that read in part, … “Effective from 01/31/25… New Orders: SN using aseptic technique, universal precautions to perform wound care to left lower leg non-pressure ulcers as follow: cleanse wound with wound cleanser using 4x4 gauze, pat dry using 4x4 gauze, apply Neosporin to peri wound, apply Fibrocal, then Hydrofera blue dressing to wound, then apply oil emulsion gauze, cover with gauze, wrap with kerlix and secure with Ace Bandage.” … Continued review of Patient #3's electronic record revealed a faxed order form titled, Physician's Order and Signatures" that was dated 02/12/25 that read in part, ..." use lidocaine, collagen, adaptic..."... Continued review of Patient #3's electronic record revealed a form titled, "Diagnosis, Assessment & Plan" that was signed and dated on 02/13/25 at 0708 read in part..." ok to use Neosporin to peri wound ..."... Review of Patient #3’s electronic record revealed SN notes that were signed and dated by LVN H on 02/14/25 and 02/17/25 read in part, … “SN cleansed left lower leg ulcers with normal saline, pat dried with gauzes, applied Hydrofera Blue ready dressing…” … Further review of Patient #3’s electronic record failed to reveal documentation of on an MD order to continue previously ordered wound care effective 1/31/25. During an interview and record review on 02/27/25 at 10:23 a.m. with the Adm/ DON (present) and LVN H on conference call, the surveyor presented the above findings. The Surveyor asked wound care was performed on SN visit notes dated 02/14/25 and 02/17/25. LVN H stated that she had applied Neosporin to the peri wound (area surrounding the wound), Fibrocal, hydrofera blue and oil of emulsion because Patient #3 did not get the lidocaine until the 19th of February and that was the date the order dated 02/12/25 was implemented. The Surveyor asked if she had received an order to continue with previous wound care orders. LVN H stated, “yes, from Staff Y from Wound Care Center Z.” The Surveyor then asked LVN H if she had written the wound care order. LVN H stated, “no, I forgot.” The Surveyor then asked what the consequences would be if the wound care was not followed. LVN H stated, “pain would increase.” Review of the agency's policy manual revealed a policy titled “Orders for Care” PC.30 with a reviewed date of 05/02/24. The policy revealed in part: … “The Agency will obtain orders and provide care in accordance with physician’s and/or non-physician practitioner’s order which are established prior to initiating patient/client care and reviewed/revised by the physician and /or non-physician practitioner every sixty (60) days and as needed.” … “I. All orders are kept current and renewed or updates as appropriate when: A. Changes in the patient’s /client’s condition occur. B. The ordered care is ineffective. C. Changes in diagnosis, treatment (including procedures and medications), and equipment occur.” …
Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to enforce its written policy to assure communication with all physicians involved in the plan of care for 1 of 5 Active Patients (#1) whose records were reviewed in that: 1. LVN D did not submit documentation of coordination with the agency and physician regarding Patient #1’s family requesting the Left plantar (bottom part of big toe) 1st toe and Left dorsum (upper surface of the foot) 2nd toe to be covered with a dry dressing and secured with tape. This failure could place the agency's active patients at risk of inaccurate care and services and could result in negative health outcomes. The Findings Included: 1. Review of Patient #1’s electronic record revealed a form titled, “OASIS-E Recertification” that was signed and dated by RN G on 12/06/24 that read in part, … “Visit Interventions: … SN performed wound care orders as per wound care orders dated 11/29/24 as followed: … Wound location: Diabetic, left plantar 1st digit (hallux) (bottom part of big toe) and left dorsum (upper surface of the foot) 2nd digit (toe) Cleansed wound with saline or wound cleanser, patted dry with 4x4’s, painted wound bed with betadine and left open to air. Review of Patient # 1’s electronic record revealed a form titled, “Home Health Certification and Plan of Care” for the Certification Period of 12/07/24 to 02/04/25 with a primary diagnosis of Pressure ulcer (wound that occurs on the feet, elbows caused by constant pressure) of left heel, stage 3 (a wound opening that exposes the fatty layer of skin). Review of Patient 1’s electronic record revealed SN notes that were signed and dated by LVN D on 12/18/24, 12/20/24, 12/23/24, and 12/25/24 that revealed the Left plantar 1st toe and Left dorsum 2nd toe to be covered with a dry dressing and secured with tape. Further review of Patient #1’s electronic record failed to reveal documented evidence of coordination with the MD and agency regarding the Left plantar 1st toe and Left dorsum 2nd toe to be covered with a dry dressing and secured with tape. During an interview and record review on 02/27/25 at 10:41 a.m. with the Adm/ DON (present) and LVD D on conference call, the surveyor presented the above findings. The Surveyor asked if there was documentation of coordination with the physician and the agency regarding the wound care performed. LVN D stated, “the MD office was notified, I spoke with office Staff X, and she said it was ok.” The Surveyor then asked if there was documentation of coordination with the agency staff regarding change in wound care orders. LVN D stated, “no, I normally talk to QA/LVN J or Adm/DON.” The Surveyor then asked if there was any reason for not submitting a communication note. LVN D stated, “no, that’s just me.” The Surveyor then asked what the consequences would be if there was no documentation of coordination. LVN D stated, "nothing, it would fall on me because I didn’t properly document.” Review of the agency's policy manual revealed a policy titled "Monitoring Patient Care/Coordination of Care" PC. 45 with a reviewed date of 05/01/24". The policy revealed in part: …"1. The Agency will: A. Assure effective communication with all physicians and/or non-physician practitioners involved in the plan of care.” ….
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