Uresti Senior Assistance

“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 code and electronically transmit completed OASIS (Outcome and Assessment Information Set) assessments to the CMS (Center for Medicare and Medicaid) system within thirty days of completing the assessment of the beneficiary for 107 of 172 (62.21%) records submitted. This failure prevented the patient’s data from being made available to Center for Medicare and Medicaid (CMS) for analysis to identify agency performance levels in the provision of patient care. The findings included: Record review of IQIES “Home Health Error Summary by Agency” report for 05/01/2024 - 05/19/2025 generated from the CMS national data system during presurvey preparation on 05/19/25 revealed Agency had submitted and processed 172 assessments. The report also revealed the Agency had 107 assessments with error -3330 indicating those records were submitted after the 30th date of the M0090 (assessment) date, which equaled to 62.21% of the total assessments submitted in error. In an interview with Adm on 05/30/25 at 12:45 p.m. Surveyor presented the above findings. Adm stated QA-A was responsible for encoding and transmitting OASIS information to CMS. Adm did not dispute the errors and stated “I was not aware of that high percentage. I knew there was some but not that many.” Surveyor asked why they had late submissions for their Oasis. Adm stated, “I do not know.” Surveyor further asked how late Oasis submissions can affect patient care. Adm confirmed it does not affect client care as the agency is still following the plan of care. In further interview with QA-A on 05/30/25 at 12:55 p.m., confirmed she was responsible for encoding and transmitting OASIS information to CMS. QA-A did not dispute the errors and further confirmed she was aware of the late submissions. Surveyor asked why they had late submissions for their Oasis. QA-A stated, “The registered nurses are submitting the Oasis to quality assurance late and by the time I get them they are way pass due.” QA-A confirmed the process of the OASIS begins with the registered nurse and once complete it is sent to quality assurance for corrections, then once corrections have been completed, they are sent to her to encode and transmit. Surveyor further asked how late Oasis submissions can affect client care. QA-A stated, “Yes, because its late but no cause the RN is already the following the plan of care. I feel like it doesn’t affect patient care.” Record review of the Agency’s policy manual contained a policy titled, “LD:18”, with no date, quoted in part, “Regulatory Compliance: Agency complies with all applicable federal, state and local laws and regulations with all applicable laws and regulations.” The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information. No additional information was presented to this surveyor upon exit on 06/04/25.”

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to enforce its written policies to provide Bloodborne pathogen training as required by the Occupational Safety and Health Administration (OSHA), 29 CFR 1910.1030 and Appendix A relating to Bloodborne pathogens for 2 of 11 personnel record review (LVN A and QA-B) whose personnel records were reviewed for 2023, 2024, and 2025. This failure could place staff and agency’s current patients at risk for exposure to communicable and/or infectious diseases. The findings include: Record review of agency’s policy “Infection Control Program”, with no date, quoted in part, “Purpose: To outline agency strategy for the addressing infection control including the prevention of the spread of infectious and communicable diseases…To ensure compliance by the agency its employees contracts with…The Occupational Safety and Health Administration (OSHA), 29 CFR Part 1910.1030 and Appendix A relating to Bloodborne Pathogens…To reduce the risk of acquired or transmitted infections among Agency patients and staff through a formalized coordinated process to reduce those risks…To comply with applicable laws, regulation, guidelines, and standards…Employee health in-service education related to infection control practices to ensure a safe environment for patients and Agency personnel…”. Review of OSHA 29 CFR 1910.1030 contains the following in part: “The employer shall train each employee with occupational exposure in accordance with the requirements of this section. Such training must be provided at no cost to the employee and during working hours. The employer shall institute a training program and ensure employee participation in the program. Training shall be provided as follows: At the time of initial assignment to tasks where occupational exposure may take place; At least annually thereafter. Annual training for all employees shall be provided within one year of their previous training”. Record review of agency’s policy “Agency Education and In-service Programs”, with no date, quoted in part, “All staff members are required to attend, or provide proof of having participated in, mandatory in-service programs. These mandatory in-service training program include OSHA/Bloodborne Pathogens…Infection control…” Record review of the Agency’s policy manual contained a policy titled, “LD:18”, with no date, quoted in part, “Regulatory Compliance: Agency complies with all applicable federal, state and local laws and regulations with all applicable laws and regulations.” 1. Review of the LVN A’s personnel record revealed an employment application was completed, signed, and dated on 11/17/23. Agency rosters documented LVN A’s date of hire as 11/17/23. Further review revealed a Job description for the position of “Quality Assurance Nurse” signed and dated 11/17/23. Review of the LVN A’s personnel record included an agency form titled “Occupational Exposure to Bloodborne Pathogens” that revealed it was the last performed Bloodborne pathogen training for LVN A dated 11/17/24. Further review of the LVN A’s personnel record revealed form “Orientation/Annual Orientation: Bloodborne Pathogens…OSHA” with a revised date of 10/21/16 was incomplete and blank. LVN A’s personnel record failed to reveal it contained evidence of an initial Bloodborne Pathogen training upon hire on 11/17/23. 2. Review of the QA-B’s personnel record revealed an employment application was completed, signed, and dated 04/29/25. Agency roster documented QA-B’s date of hire as 05/19/25. Further review revealed a Job description for the position of “Quality Assurance Technician” signed and dated 05/19/25. Further review of the QA-B’s personnel record revealed form “Orientation/Annual Orientation: Bloodborne Pathogens…OSHA” with a revised date of 10/21/16 was incomplete and blank. QA-B’s personnel record failed to reveal it contained evidence of an initial Bloodborne Pathogen training upon hire on 05/19/25. Interview with administrator on 05/30/25 at 11:30 a.m., the surveyor presented the above findings and surveyor asked what the agency’s policy on Bloodborne Pathogen trainings were. Adm stated “They are done upon hire and annually.” Adm confirmed that there are no initial Bloodborne pathogens trainings for LVN A and QA-B for the years presented above and HR is responsible for personnel records and its contents. Surveyor asked why there are no bloodborne pathogen trainings for LVN A and QA-B. Adm confirmed it was overlooked. Surveyor further asked how cannot training employees upon hire for bloodborne pathogens affect patient care. Adm stated, “…If they are not trained properly, it can harm the patients if the staff is not aware or careful how to handle things or certain situations. It can harm a patient if they are not aware of this policy.” Surveyor interviewed with HR and LVN A on 06/04/25 at 12:15 a.m., the surveyor presented the above findings and surveyor asked what the agency’s policy on Bloodborne Pathogen trainings was. HR stated, “Bloodborne pathogens should be completed and a part of the package upon hire and then yearly.” HR confirmed that there are no initial Bloodborne pathogens trainings for LVN A and QA-B for the years presented above and she was responsible for personnel records and its contents. Surveyor asked why there are no bloodborne pathogen trainings for LVN A and QA-B. HR stated, “The trainings should be here; it should have been part of the package when they completed their application. I do not know why it’s not here . It was overlooked upon the hiring process.” Surveyor further asked how cannot training employees upon hire for bloodborne pathogens affect patient care. HR stated, “It can have a negative effect on patients and staff.” LVN A stated, “Not being knowledgeable on exposures could put staff and patients at risk of infections and have a negative impact.” LVN A confirmed signing a Bloodborne Pathogen training however it was not in her personnel record, and it only had a form titled “Orientation and Annual Orientation for Bloodborne Pathogen” which was blank and incomplete. The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information upon exit on 06/04/25 at 4:00 p.m. No additional documents provided by agency.”