Premier Home Health Care LLC

“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 home health agency failed to transmit OASIS assessments within 30 days of assessment completion for 4 of 404 OASIS assessments processed in the previous 12 months (Patient # 4, 8, 9, 10). Findings include: 1. Review of OASIS Final Validation reports included a late assessment transmission for Patient #4. 2. Review of OASIS Final Validation reports included a late assessment transmission for Patient #8. 3. Review of OASIS Final Validation reports included a late assessment transmission for Patient #9. 4. Review of OASIS Final Validation reports included a late assessment transmission for Patient #10. 5. During an interview on 04/16/2025 at 3:12 PM, the Office Manager indicated she was the person who transmitted the OASIS assessments. The Office Manager indicated she remembered one late transmission in the past 12 months, and that was due to the clinician not closing the assessment in time.”

“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 governing body approved the frequency and detail of data collection for 1 of 1 agency QAPI program. Findings include: 1. Review of the QAPI policy, revised 01/21/2025, indicated “… The frequency and detail of the data collection must be approved by the governing body…” 2. Review of the governing body meeting minutes failed to include approval of the frequency and detail of data collection for the agency’s QAPI program. 3. During an interview on 04/16/2025 at 4:02 PM, the CM indicated the governing body oversees QAPI, but she did not see the governing body’s approval of the frequency and detail of data collection in the governing body meeting minutes.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, record review, and interview, the home health agency failed to ensure infection control policies and procedures related to bag technique were followed for 1 of 1 PT home visit observations (PT 1). Findings include: 1. Review of the Nursing Bag policy, revised 03/20/2023, indicated “… All items removed from the bag should be cleaned before returning to the bag…” 2. On 04/14/2025 at 8:32 AM, PT 1 was observed providing care for Patient #1. PT 1 placed the clinician bag on a barrier on the patient’s floor and failed to close the clinician bag during the visit when it was not being accessed. PT 1 further wiped the tablet and stylus used during the visit with disinfectant wipes and allowed two minutes wet time before placing the tablet and stylus into the clinician bag. PT 1 failed to place the bag on a surface that was not the floor and failed to close the bag when it was not being accessed. PT 1 failed to allow the manufacturer’s recommended wet time of four minutes before placing the tablet and stylus into the clinician bag. 3. During an interview on 04/14/2025 at 9:20 AM, PT 1 indicated he usually puts the clinician bag on the floor during a visit and sometimes leaves the bag open during the visit. PT 1 further indicated the manufacturer’s wet time for the disinfectant wipes used during the visit was four minutes. 4. During an interview on 04/14/2025 at 3:18 PM, the CM indicated it probably wasn’t the best idea for bags to be placed on the floor, and they shouldn’t be left open on the floor. The CM further indicated items should remain wet for the manufacturer’s recommended wet time before being placed into the bag.”