Suncrest 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 record review and interview, the Home Health Agency (HHA) failed to ensure the timely submission of OASIS (Outcome and Assessment Information Set) to IQIES (Internet Quality and Improvement and Evaluation System). The failure had the potential to affect all patients receiving services from the HHA who require evaluation and care. Findings included: Review of the agency’s policy titled, “OASIS Data Capture, Transmission, Verification, Display and Reports,” revised 03/01/21, revealed, “Purpose: To ensure proper OASIS data capture and transmission to state agencies and to ensure compliance with regulatory guidelines. 2. Transmittal of OASIS information a. At least monthly, Agency will electronically transmit . . . locked OASIS data to the state. All OASIS assessments completed must be transmitted within 30 days of the M0090 (assessment completion date) date. The agency’s OASIS submission data since Quarter 3, 2024 was reviewed for timely transmission to IQIES. The data revealed late transmissions over the state’s threshold of 10.0% per quarter for four of the four quarters. A total of 12 assessments were transmitted late. This resulted in an error code of -3330 (late submission). During an interview on 08/22/25 at 11:20 AM, the interim Executive Director was asked about the delay in transmitting the OASIS information. The interim Executive Director stated they were unaware of the late OASIS submissions.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record reviews, interview, and policy review, the Home health Agency (HHA) failed to produce a discharge summary and failed to ensure a discharge summary had been sent to the physician within five days of the patient’s order for discharge for two of two patients reviewed, (Patient (P)8 and P9), for completion of the discharge summary. The HHA’s failure to complete a discharge summary places patients at risk for inappropriate continuum of care services. Findings included: Review of the Home Health Agency’s policy titled, “Patient Discharge/Transfer Process,” with a review date of 10/01/23, directed staff, “. . . A discharge summary is to include admission and discharge dates, reason for admission to home health, reason for discharge, services provided, progress toward goals, patient’s discharge goals of care, patient’s treatment preferences, a list of community resources or referrals made, along with a current medication list is sent to the physician or other healthcare professional responsible for care after discharge from the agency within 5 business days of patient’s discharge . . .” 1. Review of P8’s Electronic Medical Record (EMR) under the orders tab revealed an admission date of 05/27/25 with diagnoses including multiple rib fractures, fractured vertebrae, and a broken foot. The physician’s orders included Physical Therapy one time a week for four weeks. P8 was discharged from the HHA on 07/25/25. Review of P8’s EMR revealed no discharge summary. 2. Review of P9’s Electronic Medical Record (EMR) under the orders tab revealed an admission date of 06/17/25 with diagnoses including diabetes, kidney failure and colostomy (a surgical procedure which creates an opening from the large intestine through the abdominal wall). P8 was discharged from Home Health on 08/15/25. The physician’s orders included a skilled nurse to visit one time a week for nine weeks. Review of P9’s EMR revealed no discharge summary. During an interview on 08/22/25 at 10:35 AM, the acting Executive Director confirmed the HHA failed to document a discharge summary and send the summary to the attending physician for P8 and P9.”