Adoration Home Health

“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 the Centers for Medicare & Medicaid Services (CMS) Home Health Agency (HHA) Error Summary by Agency report, review of policy “Oasis Date Capture, Transmission, Verification, Display and Reports,” and staff interview, it was determined that the agency failed to electronically transmit monthly Outcome and Assessment Information Set (OASIS) data collected to the CMS system every 30 days. Findings included: Review of the policy titled “Oasis Data Capture, Transmissions, Verification, Display and Reports,” revised 10/01/25, revealed that the agency will transmit accurate, completed, encoded and locked OASIS data to the state agency. All OASIS assessments completed must be transmitted within 30 days of M0090 date. Review of CMS report summary 01/01/2025-01/14/2026 ran on 01/14/2026 titled “HHA Error Summary by Agency,” revealed the agency failed to transmit OASIS data to the CMS system within 30 days. An interview was conducted with the Branch Director at 03/06/2026 at 1:00 PM. The Branch Director confirmed 18 OASIS reports had not been submitted to CMS within 30 days of completing the assessments.”

“Disclosure of ownership and management info. CFR(s): 484.100(a) The HHA must comply with the requirements of part 420 subpart C, of this chapter. The HHA also must disclose the following information to the state survey agency at the time of the HHA’s initial request for certification, for each survey, and at the time of any change in ownership or management: (1) The names and addresses of all persons with an ownership or controlling interest in the HHA as defined in §420.201, §420.202, and §420.206 of this chapter. (2) The name and address of each person who is an officer, a director, an agent, or a managing employee of the HHA as defined in §420.20l, §420.202, and §420.206 of this chapter. (3) The name and business address of the corporation, association, or other company that is responsible for the management of the HHA, and the names and addresses of the chief executive officer and the chairperson of the board of directors of that corporation, association, or other company responsible for the management of the HHA. This Standard is not met as evidenced by: Based on record review and staff interviews, it was determined that the agency failed to notify the State agency of a facility name change. Findings included: Review of the records revealed an email document dated 03/03/2026, revealed the agency submitted an application for name change to the Health Facility Regulation Department. An interview was conducted with the Branch Director on 03/03/2026 at 2:00 PM, who verbalized she was unsure if the agency had applied to change the name of the agency to the state department. During an interview on 03/03/2026 at 3:30 PM with the Area Vice President confirmed the agency failed to submit an application for the name change of the agency to the state department.”

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on record review and staff interview, it was determined that the agency failed to assume full legal authority and responsibility for the agency’s overall management; specifically, the agency failed to notify the State agency with a facility name change. Findings included: Review of the records revealed an email document dated 3/3/26 revealed the agency submitted an application for name change to the Health Facility Regulation Department. An interview was conducted with the Branch Director on 03/03/2026 at 2:00 PM, who verbalized she was unsure if the agency had applied to change the name of the agency to the state department. During an interview on 03/03/2026 at 3:30 PM, with the Area Vice President confirmed the agency failed to submit an application for the name change of the agency to the state department.”