Robinson Creek Home Health and Hospice

“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 18 of 907 assessments processed for the time-period reviewed of 05/02/2024 to 05/02/2025. 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 HHA Error Summary Report for the time period of 05/02/2024 to 05/02/2025 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 18 assessments and the percentage of assessments with this error was 1.98% of assessments completed by the Agency. In an interview completed with the Administrator on 05/07/2025 at 1:01 PM, the surveyor showed the administrator the “Home Health Error Summary” report which indicated that 18 OASIS assessments were late. The surveyor asked the administrator why assessments were submitted late to OASIS. The administrator reported that there had been an issue with client Medicare number changes. The assessment gets submitted with the client’s new Medicare number, but it is not getting connected to their old Medicare number and therefore it is showing as late. The administrator reported that they are the person responsible for submitting assessments to OASIS and that they do so daily, and that they have been trying to communicate with CMS to get the issue corrected. The surveyor asked if the administrator if she thought that this impacted client care. The administrator responded “no, all clients are continuing to receive the care that is ordered, despite the HHA not being reimbursed timely.” Review of the Agency’s policy titled “OASIS Compliance,” dated 2019, revealed that “within 30 days of completion (M0090), OASIS data elements will be encoded and electronically transmitted to the national OASIS system.””

“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 include all skilled professionals in their QAPI meetings in 6 out of 6 QAPI meetings (1/18/22, 12/15/22, 2/14/23, 12/19/23, 1/15/24, and 12/17/24) in the 3 years reviewed (2022, 2023, and 2024). Failure of the agency to have all disciplines of skilled professionals represented in the QAPI program resulted in missed opportunity for the therapists and MSW to provide clinical input on best practices and contribute to improving patient care. Findings included: Review of document titled “QAPI Committee Meeting Minutes.” dated 1/18/2022, revealed that attendees included the Alternate Administrator/Supervising Nurse, Administrator, PAS Supervisor, Medical Director, Alt SN, and RN A. Review of the document titled, “Zoom Meeting Log,” dated 1/18/2022, revealed that the following individuals attended the same meeting via Zoom: RN C, ST A, PT, B, LVN B, PT C, Marketing Staff A, and HHA B. According to this record, no OT or MSW attended the 1/18/22 QAPI meeting in person or via Zoom. Review of document titled “QAPI Committee Meeting Agenda.” dated 12/15/2022, revealed that attendees included the Administrator, Alternate Administrator/Supervising Nurse, Medical Director, Alt SN, RN A, PT A, and PAS Supervisor. According to this record, no OT, ST, HHA, or MSW attended the 12/15/22 QAPI meeting. There was not a matching Zoom record available for this meeting. Review of document titled “QAPI Committee Meeting Agenda.” dated 2/14/2023, revealed that attendees included the Administrator, Alternate Administrator/Supervising Nurse, Medical Director, Alt SN, PAS Supervisor, PT A, LVN A, and RN D. Review of the document titled, “Zoom Meeting Log,” dated 2/14/2023, revealed that the following individuals attended the same meeting via Zoom: RN C, OT A, RN E, MA A, PT C, Marketing Staff A, and ST B. According to these records, no HHA or MSW attended the 2/14/23 QAPI meeting in person or via Zoom. Review of document titled “QAPI Committee Meeting Agenda.” dated 12/19/2023, revealed that attendees included the Administrator, Alternate Administrator/Supervising Nurse, Medical Director, Alt SN, PAS Supervisor, RN A, LVN A, PT A, RN D, and Marketing Staff A Review of the document titled, “Zoom Meeting Log,” dated 12/19/2023, revealed that the following individuals attended the same meeting via Zoom: OT A, HHA A, RN C, MD A, and PT C. According to these records, no ST or MSW attended the 12/19/23 QAPI meeting in person or via Zoom. Review of document titled “QAPI Committee Meeting Agenda.” dated 1/15/2024, revealed that attendees included the Administrator, Alternate Administrator/Supervising Nurse, Medical Director, Alt SN, PT A, RN A, RN D, Case Manager A, and Marketing Staff A. According to these records, no ST, OT, HHA or MSW attended the 1/15/2024 QAPI meeting. There was not a matching Zoom record available for this meeting. Review of document titled “QAPI Committee Meeting Agenda.” dated 12/17/2024, revealed that attendees included the Administrator, Alternate Administrator/Supervising Nurse, Medical Director, Alt SN, PAS Supervisor, RN A, PT A, RN D, Marketing Staff A, and Case Manager A. Review of the document titled, “Zoom Meeting Log,” dated 12/17/2024, revealed that the following individuals attended the same meeting via Zoom: OT A, HHA A, MSW, MD A, and RN D. According to these records, no ST attended the 12/17/2024 QAPI meeting in person or via Zoom. In an interview with the Administrator on 5/7/25 at 11:35 AM, the Administrator reported that she was unaware that a PT would have to attend QAPI meetings because often they are contracted. 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, ST, home health aides, and personal attendant services. The surveyor asked if clients were receiving services from all those disciplines within the past 3 years. The Administrator responded they did not start providing PAS services until 2023, but all other services have been provided in 2022, 2023, and 2024. In an interview with the Administrator on 5/7/25 at 12:146 AM, the Surveyor verified the attendance of the QAPI meetings for 2022, 2023, and 2024 with the Administrator. The administrator stated she would double check meeting logs to see if anyone else had attended the meetings via Zoom. The Surveyor asked who was responsible for setting up QAPI meetings and deciding who attended. The administrator stated that was her responsibility. Surveyor showed the administrator the agency’s QAPI policy and asked the administrator who encompasses the governing body of the agency? The administrator stated that she believed the governing body included her and the Alternate Administrator. The surveyor asked why ST, OT, PT, MSW, and a HHA was not included in all of the QAPI meetings since they offer those services to patients. The Administrator stated she never thought to consistently include various therapies because they were incorporated into case conferences. The Administrator reported that most of the patients who receive therapy receive PT and they have fewer ST and OT patients, so they only thought to include the PT. The Administrator stated that the HHA is very busy and so it is very hard to pull her for QAPI, but that they do “call in” to the meeting occasionally. The Administrator stated that they do not have a lot of patients who receive SW or HHA and so they have not been including them. The Surveyor asked the Administrator if they thought not having all skilled professionals participate in QAPI impacted patient care. Administrator reported that she did not think it impacted patient care. She stated that as a small agency they are able to relay the information to everyone who did not attend. Record review of agency binder labeled “QAPI”, revealed a document, untitled and undated, which read in part: “THE QAPI Committee must include - the agency administrator - the supervising nurse or therapist, or the supervisor of an agency licensed to provide personal assistance services - an individual representing the scope of services provided by the agency.” Further review of agency binder labeled “QAPI”, revealed a document titled “Activities for Monitoring and Evaluation,” undated, which read in part, “The Administrator is responsible for the QAPI program. A QAPI Committee, consisting of the Administrator, the Administrator, and a representative of the scope of practices, will assist with the operation of the QAPI program on an on-going basis. The data will be reviewed by the Administrator and a written report will be submitted to the Administrator, Board of Directors and Board of Directors.” Record review of the agency policy titled, “Quality Assessment ad Performance Improvement – Texas,” revealed a document that read, in part, “The governing body must ensure the program reflects the complexity of its organization and involves all services provided by the Agency including those provided under contract or arrangement.” Further review of the policy read in part, “The QAPI Committee shall consist of at least the administrator, the Clinical Manager/Agency Director (Supervising Nurse)/Therapist and an individual representing the scope of services provided by the agency.””