Cj’s Abundant Care

“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 ensure OASIS transmissions were sent on time for 1 of 1 agency. Findings include: 1. Review of the undated Encoding and Reporting OASIS Data policy, indicated “… Agency will encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the client, Validation reports will be obtained and reviewed to determine if corrections are needed. 2. Review of an OASIS Agency Final Validation report for the period 01/01/2023 to 12/31/2023 indicated the following: On 12/05/2022 an OASIS assessment of Patient #5 was completed and was transmitted on 01/27/2023, 53 days later. On 12/19/2022 an OASIS assessment of Patient #5 was completed and was transmitted on 01/27/2023, 39 days later. On 12/26/2022 an OASIS assessment of Patient #5 was completed and was transmitted on 01/27/2023, 32 days later. On 11/22/2022 an OASIS assessment of Patient #3 was completed and was transmitted on 01/27/2023, 66 days later. On 01/03/2023 an OASIS assessment of Patient #10 was completed and was transmitted on 03/03/2023, 60 days later. On 01/20/2023 an OASIS assessment of Patient #3 was completed and was transmitted on 03/03/2023, 43 days later. On 03/21/2023 an OASIS assessment of Patient #3 was completed and was transmitted on 05/11/2023, 51 days later. On 05/04/2023 an OASIS assessment of Patient #6 was completed and was transmitted on 06/06/2023, 33 days later. On 05/23/2023 an OASIS assessment of Patient #3 was completed and was transmitted on 07/06/2023, 44 days later. On 06/30/2023 an OASIS assessment of Patient #10 was completed and was transmitted on 08/08/2023, 39 days later. On 06/29/2023 an OASIS assessment of Patient #6 was completed and was transmitted on 08/08/2023, 40 days later. On 08/24/2023 an OASIS assessment of Patient #5 was completed and was transmitted on 10/23/2023, 60 days later. On 08/29/2023 an OASIS assessment of Patient #10 was completed and was transmitted on 10/23/2023, 55 days later. On 09/19/2023 an OASIS assessment of Patient #3 was completed and was transmitted on 10/23/2023, 34 days later. On 08/31/2023 an OASIS assessment of Patient #6 was completed and was transmitted on 10/23/2023, 53 days later. On 08/11/2023 an OASIS assessment of Patient #11 was completed and was transmitted on 10/23/2023, 73 days later. On 08/31/2023 an OASIS assessment of Patient #12 was completed and was transmitted on 10/23/2023, 53 days later. 3. Review of an OASIS Agency Final Validation report for the period 01/01/2024 to 10/29/2023 indicated the following: On 10/24/2023 an OASIS assessment of Patient #5 was completed and was transmitted on 01/18/2024, 86 days later. On 11/07/2023 an OASIS assessment of Patient #5 was completed and was transmitted on 01/18/2024, 72 days later. On 11/17/2023 an OASIS assessment of Patient #5 was completed and was transmitted on 01/18/2024, 62 days later. On 10/31/2023 an OASIS assessment of Patient #10 was completed and was transmitted on 01/18/2024, 79 days later. On 10/31/2023 an OASIS assessment of Patient #3 was completed and was transmitted on 01/18/2024, 79 days later. On 10/31/2023 an OASIS assessment of Patient #6 was completed and was transmitted on 01/18/2024, 79 days later. On 12/05/2023 an OASIS assessment of Patient #2 was completed and was transmitted on 01/18/2024, 44 days later. On 10/31/2023 an OASIS assessment of Patient #12 was completed and was transmitted on 01/18/2024, 79 days later. 4. Review of QAPI meeting minutes indicated the following: In the 2023 Quarter 1 minutes, dated 04/19/2023, two of the six late transmissions were identified as late. No trends were noted. In the 2023 Quarter 2 minutes, dated 07/12/2023, one of the two late transmissions was identified as late. No trends were noted. In the 2023 Quarter 3 minutes, dated 10/23/2023, none of the three late transmissions were identified. No trends were noted. In the 2023 Quarter 4 minutes, dated 01/31/2024, none of the six late transmissions were identified. No trends were noted. In the 2024 Quarter 1 minutes, dated 04/22/2024, none of the eight late transmissions were identified. No trends were noted. 5. During an interview on 10/29/2024 at 3:16 PM, the Biller indicated she checks whether there are any OASIS assessments to submit about every six weeks. The Biller further indicated she thought OASIS assessments were supposed to be submitted within 30 days of the assessment and that some of the transmissions may have been late because they were put in late or some might have just gotten transferred late. The Biller indicated the Administrator was responsible for obtaining and reviewing the validation reports. 6. During an interview on 10/29/24 at 3:20 PM, the Administrator indicated she oversees the OASIS transmissions by receiving the printout from the Biller and reviews them in QAPI.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure patients were provided with the Administrator’s contact information, including name, in order to receive complaints for 1 of 1 agency. Findings include: 1. Review of the undated Home Care Bill of Rights policy indicated “Clients and their representatives will be informed of their rights as a consumer of home care services prior to the start of care.” 2. Review of the agency admission packet included a section titled “Patient’s Rights & Responsibilities” which indicated complaints or questions may be registered with Person 1, a former agency Administrator. 3. During an interview on 10/29/24 at 1:46 PM, the Administrator indicated the old Administrator was listed in the admission packet, and it should have been the current Administrator. The Administrator further indicated the Human Resources staff copied it from the master and must have forgotten to change the Administrator. 4. During an interview on 10/29/24 at 1:51 PM, the Human Resources person indicated the master copy was the same as what was in the admission packet, and she must have missed that when she updated the packet.”