Every finding on record at Ways LLC

*EMERGENCY PREPAREDNESS* Survey conducted 03/30-04/20/2026 revealed the above facility meets all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.

*CLEVELAND* The Medicare Recertification survey conducted 03/30-04/02/2026 revealed the facility was in compliance with the Medicare Conditions of Participation for Home Health Agencies (HHA). However, Standard-level deficiencies were cited. _________________________________

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 staff interview, policy and procedure review, and review of the facility report “HHA Error Summary by Agency”, the facility failed to encode and electronically transmit each completed Outcome and Assessment Information Set (OASIS) assessment within 30 days of completing the assessment of the beneficiary for 198 patients in the past 12 months: 03/26/2025- 03/26/2026. Findings Include: An Interview with the Regional Administrator on 03/30/2026 at 3:30 p.m. confirmed she is aware of the HHA Error Summary report on the timely submission of OASIS data submission to Centers for Medicare & Medicaid Services (CMS). Review of the facility’s Internet Quality Improvement and Evaluation (iQIES) Report, “HHA Error Summary by Agency” for the report period of 03/26/2025-03/26/2026 revealed, “…Error # -3330…record submitted late: the submission date is more than 30 days after M0090 on this new record…# of assessments with error 198…% of assessments with error 2.17%...”. Review of the facility’s policy, “OASIS Data Transmission”, Policy No. 3-020.1 with revision date of 12/2024, confirmed, “…Purpose: To outline the OASIS data transmission requirements…Procedure: The organization will encode and electronically transmit completed OASIS data to the national Internet Quality Improvement Evaluation System (IQIES) for each applicable patient within thirty (30) days of completing the assessment of the patient…The organization must electronically transmit accurate, complete and encoded OASIS data for each patient to the IQIES (Internet Quality Improvement and Evaluation System) ASAP (Assessment and Submission and Processing System) or CMS OASIS contractor at least monthly…” During the Exit conference on 04/02/2026 at 2:00 p.m. with Regional President via TEAMS, Regional Administrator, Branch Director- Cleveland, MS and Clinical Care Manger- Cleveland, MS. Survey findings were discussed and no further information was provided for review.