Nightingale Services

“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 transmit completed OASIS [ group of standard data HHAs integrate into their comprehensive assessment, to collect and report quality data to the CMS] assessments within 30 days of completion date in 3 of 12 (April 2024 through June 2024) months of transmissions reviewed. This failure prevented the patient’s data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. The Findings Included: Review of pre -survey report 12/16/2024, titled “HHA ERROR Summary by Agency” for reporting period 12/16/2023 to 12/16/2024 revealed that the agency had 257 (85.67%) number of assessments with error warning of “-3330: Record Submitted late: The submission date is more than 30 days after M0090 [ assessment] on this record”. On 12/17/2024 at 3:35 p.m. the Adm stated that he did not have access to all the requested error report of OASIS Agency Final Validation reports; he said he only had access to the ones when he took over as Adm. On 12/19/2024 at 12:50 p.m. the Adm stated he could not provide OASIS validation reports for 6 months request (December 2023 to June 2024). The Adm said he did not have OASIS validation reports prior to May 2024. The Adm provided print out of OASIS validation reports for April 2024, May 2024, and June 2024. Review of report 12/19/24 titled “HHA ERROR Summary by Agency” for reporting period 12/01/2023 to 06/30/2024 revealed that the agency had 123 (72.35%) number of assessments with error warning of “-3330: Record Submitted late: The submission date is more than 30 days after M0090 [ assessment] on this record”. Reports for the OASIS Agency Final Validation report revealed submission date of 04/19/2024 with 7 submitted records. 5 of the 7 records had the -3330 error code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/03/2024 with15 submitted records. 12 of the 15 records had the -3330 error code. Reports for the OASIS Agency Final Validation report revealed submission date of 05/24/2024 with 7 submitted records. 6 of the 7 records had the -3330 error code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/13/2024 with 15 submitted records. 11 of the 15 records had the -3330 error code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/14/2024 with 1 submitted record. The 1 record had the -3330 error code. Reports for the OASIS Agency Final Validation report revealed submission date of 06/21/2024 with 8 submitted records. 7 of the 8 records had the -3330 error code. During an interview on 12/17/2024 at 3:45 pm with the Adm the Surveyor asked who was responsible for transmitting the OASIS data. The Adm stated that he was responsible for transmitting the data. The Surveyor asked why the assessments were not transmitted 30 days from completion. The Adm said he knew they were late, and he put in place a new QA team. The Adm said the previous owner had the director of nursing doing the reports, but the previous director of nursing died suddenly, and the old owner did not know anything about transmitting the OASIS data, so the old owner didn’t do them. The Adm stated that he was trying to catch up and said he had been working on getting them transmitted since he took over as the Adm for the HHA. The Adm said the other problem was the SNs were not finishing and turning in the OASIS after an assessment was completed on time which caused delays in transmitting before deadline. In a continued interview the Surveyor asked what the risk to the patients was if the OASIS data was not submitted on time. The Adm stated it delayed the data being provided to Medicare to show what improvements could be done for patients for the agency and nationally; and for nursing it delayed guidance on how they were doing with patient care. The Adm added that a system was put in place that said every OASIS had to be finished and ready to export within 5 days. The Surveyor asked who would be responsible for overseeing the timely completion and submission of the OASIS. The Adm identified himself and the new QA team as the persons responsible. Review of agency’s policy titled “OASIS Collecting, Encoding and Transmitting”, dated 010121, read in part, “B. The Agency must electronically report all OASIS data collected … C. 484.45(a) Encoding and transmitting OASIS data. 1. The Agency must encode and electronically transmit each completed OASIS assessment to the CMS system… within 30 days of completing the assessment of the beneficiary…””