Nhc Homecare - Low Country

“Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: Based on observations, record review, and interviews, the Home Health Agency (HHA) failed to develop and implement policies and procedure for the uses of volunteers in an emergency. The HHA’s failure to include the use of volunteers and other staffing strategies during an emergency has the potential to place all 54 patients at risk for unmet needs. Findings include: Review of the HHA’s Emergency Preparedness plan, last reviewed 01/2020, revealed “*NOTE: NHC HomeCare does not utilize volunteers.” An interview with the Administrator on 09/04/25 at 3:30 PM confirmed the HHA does not have a plan or procedure for the use of volunteers during an emergency and was unaware of the need to include volunteers in the HHA’s Emergency Preparedness plan.”

“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 include: Review of the agency’s policy titled, “OASIS and OASIS DATA MANAGEMENT” reviewed on 09/24, revealed the policy is “To ensure the collection, processing, submission and maintenance of OASIS data…” The policy states the OASIS date is (to be) encoded and transmitted to CMS via the OASIS QIES (sic) as required…within 30 days.” The agency’s OASIS submission data for Quarter (Q) 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 nine assessments were transmitted late. This resulted in an error code of -3330 (late submission). During an interview on 09/04/25 at 10:00 AM, the Administrator was asked about the delay in transmitting the OASIS information. The Administrator stated they were unaware of the late OASIS submissions.”