Remarkable 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 Agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the patient for 6 of 1141 assessments processed for the time-period reviewed of 05/11/2024 – 5/11/2025. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare and improve patient care failing to be reported to CMS in the required time frame. Findings included: Review of the Home Health Agency Error Summary Report for the period of 05/11/2024 – 5/11/2025 identified Error #-3330. The description for Error #-3300 read in part, “Record Submitted Late: The submission date was more than 30 days after M0090 (item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with this error was 6 assessments and the percentage of assessments with this error was 0.53% of assessments completed by the Agency. In an interview completed with the Administrator on 05/14/2025 at 3:03 PM, the surveyor showed the Administrator and Compliance Personnel A the “Home Health Error Summary” report which indicated that 6 OASIS assessments were late. The surveyor asked the Administrator and Compliance Personnel A why assessments were submitted late to OASIS. The administrator and Compliance Personnel A reported that these submissions were labeled as late because they went back and made corrections to a few assessments, and when the corrections are saved, OASIS counts this as a new submission and it is classified as late, even though the original assessment was submitted on time. Compliance Personnel A explained that some of the patients had a change in their Medicaid number, and when they updated in OASIS it counted the assessment as late. The surveyor asked if the Administrator if she thought that this impacted client care. The administrator responded that she did not think so because all patients were still receiving their plans of care on time and getting the services they needed. The surveyor asked who was responsible for submitting and updating assessments to OASIS. The administrator stated that it was Compliance Personnel B, whose title was “RN Compliance”. In a phone interview completed with Compliance Personnel B on 5/14/2025 at 3:17 PM, the surveyor asked if it was part of her role to ensure the timely transmission of OASIS assessments, and she replied that it was. The surveyor stated that 6 of 1141 assessments submitted in the last year were submitted after the 30 days required by OASIS. The surveyor asked what the reason for this was. Compliance Personnel B stated that it was likely due to the assessments they had to go back and edit, because when that occurs after 30 days from the M0090 date they are considered late. Surveyor asked what processes the agency has in place to ensure assessments were submitted in a timely manner. Compliance Personnel B stated that they ran an OASIS audit report daily and looked at the visit date to make sure assessments were submitted on time. The surveyor asked if she thought this impacted patient care. Compliance Personnel B stated she did not think so because it was more of a “process thing” and that by that time the patients already received care. Review of the Agency’s policy titled “OASIS Compliance,” dated December 2023, revealed that “the M0090 (Date Assessment Completed) will indicate the last day the assessing clinician gathered or received any input used to complete the comprehensive assessment.” Further review revealed that, “On a Start of Care (SOC) episode, the SOC assessment OASIS data elements will be encoded and transmitted to the national OASIS system within 30 days of completion (M0090). For a recertification assessment, the OASIS data elements will be encoded and transmitted to the national OASIS system within 30 days of completion (M0090).””

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on record review and interview, the agency failed to staff its QAPI meetings with required agency staff in 12 out of 12 QAPI meetings (1/13/2022, 4/14/2022, 7/13/2022, 10/13/2022, 1/16/2023, 4/14/2023,7/18/2023, 10/17/2023, 1/23/2024, 4/18/2024, 7/19/2024, and 10/15/2024) in the 3 years reviewed (2022, 2023, and 2024). Failure of the agency to have someone representing all services provided by the agency in the QAPI program resulted in missed opportunity for the administrator, therapists, and MSW to provide clinical input on best practices and contribute to improving client care. Findings included: Review of document titled “QAPI Meeting Attendance Roster,” dated 1/13/2022, revealed that attendees included the Previous Administrator A, Previous SN, MD A, PTA A, and PT-A. According to this record, no OT or MSW attended the 01/13/2022 QAPI meeting. Review of document titled “QAPI Meeting Attendance Roster,” dated 4/14/2022, revealed that attendees included the Previous Administrator A, PT-A, ST A, and OT A. According to this record, no MSW attended the 4/14/2022 QAPI meeting. Review of document titled “QAPI Committee Meeting Minutes” dated 07/13/2022, revealed that a QAPI meeting was held on 07/13/2022. The document revealed that “review of minutes approved by RN A and second by MSW A.” According to this record, no PT, ST, or administrator attended the 07/13/2022 QAPI meeting. No corresponding attendance roster for this meeting was available to review and therefore attendance history could not be obtained. Review of document titled “QAPI Committee Meeting Minutes” dated 10/13/2022, revealed that a QAPI meeting was held on 07/13/2022. The document revealed that “review of minutes approved by PTA A and second by RN A.” According to this record, no MSW, ST, or administrator attended the 10/13/2022 QAPI meeting. No corresponding attendance roster for this meeting was available to review therefore attendance history could not be obtained. Review of document titled “QAPI Meeting Attendance Roster,” 1/16/2023, revealed that attendees included the Previous SN, PTA A, PT-A, MD B, RN A, PTA B, ST A, and Previous Administrator A. According to this record, no OT or MSW attended the 1/16/2023 QAPI meeting. Review of document titled “QAPI Committee Meeting Agenda” dated 4/14/2023, revealed that a QAPI meeting was held on 4/14/2023. No corresponding attendance roster or meeting minutes for this meeting was available to review therefore attendance history could not be obtained. Review of document titled “QAPI Meeting Attendance Roster,” dated 7/18/2023, revealed that attendees included Previous Administrator B, Previous SN, OT/PT Owner, PTA A, MSW A, Marketer A, LVN A, PTA B, RN B, Marketer B, PT-B, Nurse A, RN C, Intake A, Intake B, HR A, and MD B. According to this record, no ST attended the 7/18/2023 QAPI meeting. Review of document titled “QAPI Committee Meeting Minutes” dated 10/17/2023, revealed that a QAPI meeting was held on 10/17/2023. The document revealed that “review last QAPI meting reviewed by Previous Administrator B.” According to this record, no MSW, ST, OT, or PT attended the 10/17/2023 QAPI meeting. No corresponding attendance roster for this meeting was available to review therefore attendance history could not be obtained. Review of document titled “Inservice Attendance Record” dated 1/23/2024, revealed that attendees included Previous Administrator B, Intake A, OT/PT Owner, PT-B, MSW A, Marketer B, PT-A, PTA C, LVN B, LVN A, HR A, RN B, and MD B According to this record, no ST attended the 1/23/2024 QAPI meeting. Review of document titled “QAPI Meeting Attendance Roster,” dated 4/18/2024, revealed that attendees included Previous Administrator B, Previous Administrator A, Previous SN, VP, PT-A, PTA C, PT-B, Nursing Supervisor, and LVN B According to this record, no OT, ST, or MSW attended the 4/18/2024 QAPI meeting. Review of document titled “QAPI Meeting Attendance Roster,” dated 7/19/2024, revealed that attendees included Previous Administrator B, Previous Administrator A, Previous SN, VP, PT-A, PTA C, PT-B, Nursing Supervisor, RN D, LVN B, LVN A, RN E, MD B, and Marketer B. According to this record, no OT, ST, or MSW attended the 7/19/2024 QAPI meeting. Review of document titled “Quality Assessment and Performance Improvement (QAPI) Meeting” dated 10/15/2024, revealed that attendees included Previous Administrator C, RN A, Intake A, Intake C, OT/PT Owner, PT-B, Marketer C, Marketer B, PT-A, PTA C, LVN A, Nursing Supervisor, LVN C, RN D, MSW A, and Compliance Personnel. According to this record, no ST attended the 7/19/2024 QAPI meeting. In an interview with the administrator and compliance personnel on 05/14/2024 at 2:00 PM, the surveyor confirmed attendance for the QAPI meetings. The Administrator and compliance personnel reported that they were unable to locate attendance sheets for 7/13/2022, 10/13/2022. 4/14/2023, and 10/17/2023 QAPI meetings. The surveyor asked if there was any way to confirm who did attend those meetings or if anyone still working with the agency knew. The Administrator responded that she was not working with this license until April 11, 2025 and the Alternate Administrator was not designated for this license until May 12, 2025, and therefore neither of them knew who attended previous meetings. The Administrator and Compliance personnel were not aware of any employee who would be able to speak on who attended those meetings that did not have sign in sheets. The Administrator and Compliance personnel acknowledged that though some of the meeting minutes for QAPI meetings included a section on membership, those listed in that corresponding membership section did not always consistently reflect who actually attended QAPI meetings. In an interview with the Administrator and compliance personnel on 5/14/2025 at 2:35 PM, the surveyor reported that QAPI meetings are required to have individuals representing the scope of their services. The surveyor confirmed with the Administrator that the services provided included SN, MSW, PT, OT, and ST. The surveyor asked if clients were receiving services from all those disciplines within the past 3 years. The Administrator and compliance personnel confirmed that clients received services from all of those services in 2022, 2023, and 2024. In an interview with the Administrator on 5/14/2025 at 2:47 PM, the Surveyor asked who was responsible for setting up QAPI meetings and deciding who attended. The administrator stated that was the SN’s responsibility. The Administrator reported that the SN was currently sick in the hospital and would not be available for an interview. The Administrator stated that she only took on the responsibility of QAPI meetings when she began working with this license in August, 2024 and therefore she would not have known why all 11 meetings reviewed prior to that date did not include representation of the full scope of services. Surveyor showed the administrator the agency’s QAPI policy and asked the administrator who encompasses the governing body of the agency? The administrator stated the governing body referred to GB A. The surveyor showed the Administrator her signed job description, which indicated she was responsible for ensuring that the QAPI reflected the program’s scope of services. The Administrator stated that she is responsible, but she delegated this task to SN. The surveyor asked why ST, OT, and MSW was not consistently included in all of the QAPI meetings since they offer those services to patients. The Administrator stated OT and ST are contracted and as needed positions and so that may have been why they were not included in the past. The Administrator acknowledged that that the QAPI policy included contractors and that she did not know why they were excluded in the QAPI meetings prior to her becoming administrator. The Surveyor asked the Administrator if they thought not having all skilled professionals participate in QAPI impacted patient care. Administrator reported “no.” In an interview with the Administrator on 5/15/2025 at 3:30 PM, the surveyor asked the Administrator for clarification on a document provided that refers to GB A as representative of the governing board of “HHA A.” The Administrator reported that HHA A is the business entity that owns HHA B and oversees them and that the document does apply to HHA B. The surveyor attempted to call GB A for an interview on 5/14/2025 at 3:15 PM and on 5/15/25 at 1:58 PM. The surveyor left a voicemail and requested a call back on both occasions but did not receive one. Record review of the agency policy titled, “Quality Assessment and Performance Improvement” dated 2023, revealed a document that read, in part, “The governing body must ensure the program:…B. Involves all services provided by the agency including those provided under contract or arrangement.” Record review of the document titled “Administrator – Home Care: Job Description”, signed and dated by the administrator on 11/11/24, revealed a description of the Administrator’s role and included the following: “As the liaison with the governing body, ensures the Quality Assessment and Performance Improvement (QAPI) Program reflects the complexity of the organization and services. Ensures QAPI includes all agency services (including those services provided under contract or arrangement).” Record review of the agency’s policy titled “Scope of Services”, dated 2024, revealed a document that read in part, “The scope of services is available upon request in agency brochures.” Review of the agency’s brochure titled, “Welcome to Our Family,” undated, revealed the following services listed under the heading “Covered Services for Home Health”: Skilled Nursing, Transitional Care Coordinator, Physical Therapy, Occupational Therapy, Speech Therapy, Medical Social Work, Home Health Aide.””