Faith Home Health Inc.

“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 interview and record review, the agency failed to electronically transmit seven completed Outcome and Assessment Information Sets (OASIS) to the Centers for Medicare and Medicaid Services (CMS) within 30 days of completing the assessment, as required. This failure resulted in seven late transmissions out of twelve records reviewed. An OASIS Set as defined by CMS is “a group of standard data elements home health agencies integrate into their comprehensive assessment, to collect and report quality data to CMS.” The findings include: A review of the agency’s Error Summary by Agency report from the Internet Quality Improvement and Evaluation System (iQIES) for year‑to‑date 1/1/26–4/15/26 identified error code -3330 (Record Submitted Late: the submission date is more than 30 days after M0090.) (M0090 refers to the date the assessment was completed, which CMS uses to determine whether the transmission occurred within the required 30‑day time frame.) The report showed seven late assessments out of twenty‑eight submitted, resulting in a 25% late‑submission rate. Late assessments included: Patient #7: data completed 12/1/25; submitted 1/25/26; and data completed 12/9/25; submitted 1/29/26Patient #8: data completed 12/1/25; submitted 1/3/26Patient #9: data completed 12/16/25; submitted 1/29/26Patient #10: data completed 1/19/26; submitted 3/12/26Patient #11: data completed 1/26/26; submitted 3/11/26Patient #12: data completed 9/29/25; submitted 4/8/26During an interview with the Alternate Administrator on 4/15/26 at 9:45 a.m., they stated that the Assistant Director of Nursing (ADON) is responsible for transmitting OASIS assessments to CMS. During an interview with the ADON on 4/15/26 at 10:00 a.m., the ADON confirmed responsibility for OASIS transmission and stated that assessments are expected to be transmitted within 30 days, adding that they typically complete transmissions within 5 days. When asked about the agency’s year‑to‑date late‑submission rate, the ADON stated, “We don’t have any late submissions.” When asked how the late‑submission rate is monitored, the ADON stated it is determined from iQIES. After being shown the error summary documenting a 25% late‑submission rate, the ADON questioned why the rate was that high and stated, “It’s probably the discharges that are late. I’m aware, but sometimes it’s difficult to have everything completed, having the nurses and physical therapists complete their sections before they lock it to be submitted.” A review of the agency policy titled “Transmission of OASIS” (revised 12/31/2020) revealed that all encoded and locked OASIS assessments are to be transmitted on a monthly basis, and no later than the end of the month. The policy also requires that report feedback from the OASIS desk be documented to confirm transmission status.”

“Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA’s governing body. This Standard is not met as evidenced by: Based on record review and interview the home health agency failed to ensure the Quality Assurance Performance Insurance Program (QAPI) measured, analyzed and traced quality indicators, including infection control, Outcome and Assessment Information Set (OASIS) data reporting and adverse patient events, that enable the home health agency to assess processes for care, services and operations. The findings include: Review of the Quarterly Quality Assurance Report revealed, “This report documents the Quality Assurance review activities completed for the period of January 5, 2025 through January 5, 2026. The review was conducted to evaluate the quality, appropriateness, adequacy, coordination, and documentation of services provided by the agency and to identify areas requiring corrective action and continued monitoring.” The report included skilled nursing, physical therapy, home health aides. “The review included a sample of both active and closed or discharged patient records. Records were reviewed for admission appropriateness, plan of care compliance, physician order timeliness, case assignment, care coordination, documentation standards and overall adherence to agency policy and procedures.” Under the section titled “Record Sample Reviewed” the area was blank and did not include information on the patient charts selected for review. Under section “Quarterly Indicator Summary” it was documented “All quality indicators reviewed scored 100% except physician signing and return of the plan of care on time, which was identified as the primary area needling close monitoring and quarterly improvement.” There is no indication in the report that infections were tracked and trended or monitoring of OASIS data timeliness was reviewed. During an interview with the Alternate Administrator on 4/15/26 at 9:45 a.m., they stated that the Assistant Director of Nursing (ADON) is responsible for transmitting OASIS assessments to CMS. During an interview with the ADON on 4/15/26 at 10:00 a.m., the ADON confirmed responsibility for OASIS transmission and stated that assessments are expected to be transmitted within 30 days, adding that they typically complete transmissions within 5 days. When asked about the agency’s year‑to‑date late‑submission rate, the ADON stated, “We don’t have any late submissions.” When asked how the late‑submission rate is monitored, the ADON stated it is determined from iQIES. After being shown the error summary documenting a 25% late‑submission rate, the ADON questioned why the rate was that high and stated, “It’s probably the discharges that are late. I’m aware, but sometimes it’s difficult to have everything completed, having the nurses and physical therapists complete their sections before they lock it to be submitted.” On 4/15/26 at approximately 11:00 AM, an interview was conducted with the Alternate Administrator who stated that they have not had patient care issues that required them to track anything. This included a lack of patient complaints, incidents, infections etc. He presented the team with the Complaint Log which had no documented complaints in the last 6 months. He stated that the QAPI committee meets quarterly and provided the team with the Quality Assurance Review activities completed for the period January 5, 2025 through January 2026. When asked if they were tracking quality indicators in which they compared themselves to the state and national averages, he stated that they did not have any concerns. At this time, he was asked to provide chart audits or other documentation for the records sampled in the Quarterly Quality Assurance Report and copies of the quarterly meetings, he stated the ADON would have that. On 4/15/26 at approximately 1:00 PM, the ADON was asked about chart audits and other record review documentation to which she stated she was not aware of these documents and was not sure why they said she would have them. The HHA annual Infection Control Report dated 1/1/2026, read “based on the annual review of surveillance data, staff education records, supervisory oversight, incident reports, and QAPI findings, the agency concludes that the infection Control Program was implemented during the review period.” A review of the HHA electronic software listing for 1/1/2025-12/1/2025 Infection List revealed no evidence of ongoing monitoring and evaluation of infection control practices. On 4/15/26 at 3:56PM, the Assistant Director of Nursing stated that the agency collects information but does not use it for monitoring or to improve performance. She also said there is no data to support the findings listed in the Annual Infection Control report. No additional information was provided by the time of survey exit.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency failed to develop and implement an effective infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to prevent the transmission of infections and communicable diseases. The HHA annual Infection Control Report dated 1/1/2026, read “based on the annual review of surveillance data, staff education records, supervisory oversight, incident reports, and QAPI findings, the agency concludes that the infection Control Program was implemented during the review period.” A review of the HHA electronic software listing for 1/1/2025-12/1/2025 Infection List revealed no evidence of ongoing monitoring and evaluation of infection control practices. On 4/15/26 at 3:56PM, the Assistant Director of Nursing stated that the agency collects information but does not use it for monitoring or to improve performance. She also said there is no data to support the findings listed in the Annual Infection Control report.”

“Classroom and supervised practical training CFR(s): 484.80(b)(1) Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Classroom and supervised practical training must total at least 75 hours. This Element is not met as evidenced by: Based on interview and record review, the agency failed to provide proof of required home health aide training consisting of at least 75 hours of classroom and supervised practical instruction for two personnel files (Staff A and E) of four reviewed. The findings include: A review of personnel files revealed that two home health aides—Employee A (hire date 3/6/26) and Employee E (hire date 6/17/25)—did not have documentation demonstrating completion of the required 75‑hour home health aide training program. Employee A: No documentation of any home health aide training was present in the personnel file. Employee E: The only document provided was a certificate labeled “International School of Health Training,” which did not include dates of training or a Department of Education school license number. The certificate did not provide evidence that the required 75‑hour training was completed. During an interview with the Alternate Administrator on 4/15/26 at 11:45 a.m., the administrator confirmed that Employee A’s file was incomplete but stated that the employee “hasn’t had a patient assignment yet.” When asked to confirm the employee’s hire date (3/6/26), the administrator confirmed it was correct. Regarding Employee E, the administrator stated they had a 75‑hour certificate. When asked to provide the training agenda or curriculum from the International School of Health Training that would verify completion of the required hours, the administrator stated they could not provide it.”