Royal Home Health Care, Incorporated

“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 electronically transmit completed OASIS (a standardized data set tool used by CMS that measures the quality and outcomes of home health patients) assessments to the CMS system for all Medicare patients within 30 days of completing the OASIS assessment of the patient for 43.10% (25 of 58) of assessments reviewed for report period dated 05/01/2025 – 04/30/2026 and for 48.65% (18 of 37) of assessments reviewed for report period dated 02/01/2026 – 08/11/2026. This failure prevented the agency’s patient data from being made available to CMS within 30 days of the OASIS completion date for analysis to identify agency performance levels in the provision of patient care. This failure also placed clients at risk of receiving inadequate care. Findings included: During pre-survey record review on 08/04/2026, the surveyor reviewed the agency OASIS report titled, “HHA Error Summary by Agency” from IQIES (a web-based system used by CMS and healthcare providers to manage survey, certification, and quality reporting data for post-acute and long-term care settings) for the period of 05/01/2025 – 04/30/2026. The report included 25 of 58 OASIS assessments (43.10%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment. During an interview with the Adm on 08/06/2026 at 1:40 PM, the Adm stated the PCR was responsible for submitting OASIS assessments to the CMS system. Record review of the QAPI binder on 08/11/2026 included a form titled, “QAPI Action Plan…” that that was signed and dated on 01/31/2026 by the Adm, Alt Adm, DON and ADON that read in part, “… Date the improvement opportunity was identified for further study… January 31, 2026 Describe the process identified as a problem or opportunity for improvement…Late OASIS Error Rate According to the CMS IQIES error summary report date ranging 01/01/2025 - 12/31/2025, the agency score for late OASIS was 30.23% with 13 errors in 43 forms submitted more than 30 days from the M0090 date. By aggravating the results and establishing a trend, the agency will be able to identify causation and develop measures to improve the score for this indicator…can lead to patient care that is possibly suboptimal or even incorrect placing both the agency and patients in a vulnerable status… In addition the state and accreditation agencies are currently citing the agencies at the GO372 tag in an apparent effort to push agencies to submit Oasis data in a regulatory compliant timeframe…” On 08/11/2026, the surveyor reviewed the agency OASIS report titled, “HHA Error Summary by Agency” from IQIES for the period 02/01/2025 – 08/11/2026 (beginning the day after the QAPI Action Plan dated 01/31/2026). The report included 18 of 37 OASIS assessments (48.65%) with Error -3330 for OASIS assessments submitted more than 30 days of completing the OASIS assessment; an increase of 5.55% from the report period dated 05/01/2025 – 04/30/2026. During an interview with the PCR on 08/11/2026 at 11:24 AM, the surveyor asked who was responsible for submitting OASIS assessments to CMS. The PCR stated the PCR was. The surveyor reviewed the agency’s QAPI Action Plan and asked why 43.10% (25 of 58) of assessments reviewed for report period dated 05/01/2025 – 04/30/2026 and 48.65% (18 of 37) of assessments reviewed for report period dated 02/01/2026 – 08/11/2026 were not submitted within 30 days of completing the OASIS assessments and why the error rate had not improved since the agency’s QAPI Action Plan dated 01/31/2026. The PCR stated it was taking the agency nurses more than 30 days to complete the OASIS assessments. The PCR further stated it also took the nurses a while to correct the visit frequencies on the OASIS assessments and for the Quality Assurance department to complete diagnosis coding for the assessments. During an interview with the Adm on 08/11/2026 at 11:40 AM, the surveyor reviewed the agency’s QAPI Action Plan and asked why 43.10% (25 of 58) of assessments reviewed for report period dated 05/01/2025 – 04/30/2026 and 48.65% (18 of 37) of assessments reviewed for report period dated 02/01/2026 – 08/11/2026 were not submitted within 30 days of completing the OASIS assessments and why the error rate had not improved since the agency’s QAPI Action Plan dated 01/31/2026. The Adm stated the agency nurses completing the assessments did not complete the assessments in a timely manner and it had been a struggle for the agency. The Adm stated the agency was trying its best but they were not where they needed to be with submitting the assessments within 30 days. The Adm further stated those were the same reasons agency policy had not been followed. Agency policy titled, 8.10 Timelines last revised 1/29/2020 read in part, “… The Agency will ensure timely provision of service and services to meet the client’s needs in compliance with all federal and state laws and regulations… All Agency staff, and physician/physician office staff as appropriate, will be oriented to the following parameters… Completed, encoded and locked OASIS data will be transmitted within thirty (30) days of the M0090 [completion] date…””