Every finding on record at Unity Homecare LLC

An Entrance Conference was conducted on 04/23/2024 with the Administrator/Alternate Supervising Nurse and the Supervising Nurse at 1:30 PM. The Agency representatives were informed the purpose of the survey was a Recertification Survey. Written information regarding "What to Expect During Your Agency's Survey" was provided. The Agency census was: L&CHHS - 172 PAS - 26 An Exit Conference was conducted on 04/25/2024 with the Alternate Administrator and the Supervising Nurse at 3:30 PM. The preliminary findings of the survey were reviewed. The Agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Violations. Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services PAS - Personal Assistance Services CMS - Centers for Medicare and Medicaid Services OASIS - Outcome and Assessment Information Set

An Entrance Conference was conducted on 04/23/2024 with the Administrator/Alternate Supervising Nurse and the Supervising Nurse at 1:30 PM. The Agency representatives were informed the purpose of the survey was a Recertification Survey. Written information regarding "What to Expect During Your Agency's Survey" was provided. The Agency census was: L&CHHS - 172 PAS - 26 An Exit Conference was conducted on 04/25/2024 with the Alternate Administrator and the Supervising Nurse at 3:30 PM. The preliminary findings of the survey were reviewed. The Agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Violations. Abbreviations/Acronyms: L&CHHS - Licensed and Certified Home Health Services PAS - Personal Assistance Services CMS - Centers for Medicare and Medicaid Services 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 encode and electronically transmit each completed OASIS assessment to the CMS system, within 30 days of completing the assessment of the patient for 85 of 1160 assessments processed within the calendar year of 2023. 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. Findings included: The HHA Error Summary Report, retrieved from the iQIES website for the calendar year of 2023 (01/01/2023 to 12/31/2023) was reviewed. Review of the HHA Error Summary Report for the time-period of 01/01/2023 to 12/31/2023 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 this error was 85 assessments and the percentage of assessments with this error was 7.33% of assessments completed by the Agency. Review of the Agency’s QAPI documentation for the year of 2023 revealed the Agency had been tracking the number of OASIS assessments with Error -3330. An interview was conducted with the Supervising Nurse on 04/25/2024 at 1:25 PM. Surveyor reviewed the HHA Error Summary Report with the Supervising Nurse. The Supervising Nurse stated the Agency had identified the timeliness of OASIS transmittals was an issue and had been monitoring this. The Supervising Nurse presented a binder with calendars used to track and ensure OASIS assessments were transmitted in a timely manner. The Supervising Nurse stated the Agency had identified an improvement in the calendar year of 2024 of the timeliness of OASIS assessment transmittals. During the exit conference on 04/25/2024 at 3:30 PM, the findings were presented to the Alternate Administrator. No additional information was provided.