Koc Healthcare Services Inc.

“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 interview and record review, the agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system regarding each beneficiary within 30 days of the comprehensive patient assessments being completed for 10.71% (3 of 28) patient assessments completed and transmitted between the dates of 8/06/2025 to 8/06/2026. “CMS system” means the national internet Quality Improvement Evaluation System (IQIES). “OASIS assessment” means the (functional, clinical, and service data items used to evaluate patients during prescribed timepoints to evaluate care needs, outcomes, and quality of care provided by home health agencies). “Encode” means to enter OASIS information into a computer. “Transmit” means electronically send OASIS information, from the HHA directly to the CMS system. This failure meant patients were subjected to the potential for poor quality care when the agency did not evaluate care needs and outcomes in a timely manner. Based on interview and record review, the agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system regarding each beneficiary within 30 days of the comprehensive patient assessments being completed for 10.71% (3 of 28) patient assessments completed and transmitted between the dates of 8/06/2025 to 8/06/2026. “CMS system” means the national internet Quality Improvement Evaluation System (IQIES). “OASIS assessment” means the (functional, clinical, and service data items used to evaluate patients during prescribed timepoints to evaluate care needs, outcomes, and quality of care provided by home health agencies). “Encode” means to enter OASIS information into a computer. “Transmit” means electronically send OASIS information, from the HHA directly to the CMS system. This failure meant patients were subjected to the potential for poor quality care when the agency did not evaluate care needs and outcomes in a timely manner. Findings Include: Review of the IQIES HHA Error Summary by Agency Report for the dates – 8/06/2025- 8/06/2026 which was run on 8/06/2026 resulted in the error -3330, Record Submission Late: The submission date is more than 30 days after M0090 (comprehensive patient assessment date) for 3 of 28 assessments resulting in a 10.71% error rate. An interview was conducted on 08.06.26 at 1:31 PM with the Administrator/ DON, who completed and signed the OASIS patient assessments reviewed during the survey. The surveyor asked what the process was for OASIS collection, encoding, and transmission, and who was responsible for ensuring the OASIS was transmitted in a timely manner. The DON stated they collected during patient assessments, and the DON was responsible for encoding and transmission. The surveyor asked about the agency’s policy on timelines for OASIS collection, encoding and transmission. The DON stated she admitted, coded, reviewed, encoded, and transmitted OASIS data. The surveyor asked why they were not all transmitted within 30 days. The DON stated: “The VA is different and we don’t do it exactly, the VA says its preauthorized and VA is not strict, so it’s about the time and we don’t follow to the letter as for Medicare patients… I have no active L and C (Licensed and Certified patients). The surveyor asked why some of the OASIS assessments were transmitted later than 30 days. The DON stated: “because I’m the only one doing it, and sometimes I forget, and as soon as I remember, I do it.” The surveyor asked if the DON had a tracking or monitoring system in place for this. The DON stated: “I have a folder, and this is what I use to write it.” The DON showed the surveyor a spiral notebook. The DON stated: “I write it, then color it pink highlighter when I transmit.” The surveyor asked the Administrator /DON if they were aware of the process and timeline requirements for OASIS collection and transmission. The Administrator stated they were aware and had no additional comments on why the deficient practice was occurring. The Administrator /DON stated, “the VA is not so strict…” Review of the agency policy titled, “Timelines IM.10” with no date read in part, “Policy- The Agency will ensure timely provision of care and services to meet the patient’s / client’s needs in compliance with all federal and state laws and regulations. Procedure … A registered nurse will complete the Initial Comprehensive assessment no later than five calendar days after the start of care (SOC) for all patient/clients in a licensed and certified agency … Encoding and locking OASIS data for the state will be completed within 30 days of completion of the Comprehensive Assessment. Completed, encoded and locked OASIS data will be transmitted to the state at least monthly...””

“OASIS privacy notice CFR(s): 484.50(a)(1)(iii) (iii) An OASIS privacy notice to all patients for whom the OASIS data is collected. This Element is not met as evidenced by: Based on observation, record review, and interviews in 3 patients (1, #2 and #3) of 4 active patients, the agency failed to provide the required Outcome and Assessment Information Set privacy notices to patients on admission for whom OASIS data was collected. This failure places client’s at risk of having their personal data shared without being informed of their privacy rights and cause mental distress. Review of the clinical records for patients #1, #2, and #3 revealed the agency completed and collected OASIS assessment data for each client. Review of the clinical records for patients #1, #2, and #3 did not contain evidence that the agency had provided the required OASIS privacy notices at the time of admission to the agency. Review of the agency’s admission packet on 08/12/2026 found the packets did not contain the required OASIS privacy notices. Observation and interview of patient #1’s record and home folder during a home visit on 08.11.26 at 1:02 PM with patient #1 found no OASIS privacy notices to the patient whose OASIS data was collected. Patient #1 stated the home folder was all that the agency provided during admission and OASIS privacy notices had not been reviewed with him by the agency staff. Patient #1 stated nothing had been removed from the home folder and nothing else was provided that wasn’t in the home folder. An interview was conducted with the Administrator / DON on 08.12.2026 at 11:15 AM via telephone (the Administrator / DON stated she was out of the country at a memorial service. The surveyor reviewed the clinical record findings, agency admission packets, and findings of home visits including the lack of the required privacy notices for patients for whom OASIS was collected. The Surveyor asked who was responsible for the contents of the admission folders and information provided to the patients upon admission. The Administrator/DON stated she was responsible and put the packets together when she went out to admit the patients and stated, “staff must have misplaced it.” The Administrator / DON stated she understood what was required. The Surveyor asked about the agency policy and procedures and if they had been updated since the January 2026 requirement for OASIS collection for all skilled patients and payers and notices to be provided during admission. The Administrator / DON stated they had not been updated.”

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on observation, record review, and interview in 3 patients (#1, #2 and #3) of 4 active patients, the agency failed to ensure patients were advised of the names, addresses, and telephone numbers of Federally funded and state-funded entities that served the area where the patient resided. This failure placed patients at risk of their rights being violated when they were not made aware of available advocacy, assistance, disability, aging, and quality-improvement resources, and to limit patients’ ability to independently access these services when needed. Review of the agency’s admission packet on 08/12/2026 and Patient rights information provided revealed the rights and resource information provided to patients did not include the names, addresses, and telephone numbers for the required federal funded and state-funded entities, including the Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. Review of the clinical records for Patients #1, #2, and #3 did not contain evidence the agency had provided the required contact information for the federally funded and state-funded entities. Observation and interview of Patient #1s client record and home folder during a home visit on 08.11.26 at 1:02 PM with Patient #1 found no contact information for the federally funded and state-funded entities. Patient #1 stated the home folder was all that the agency provided during admission and no contact information had been reviewed for the Federally funded and state-funded entities. Patient #1 stated no contact information was provided for Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and the Quality Improvement Organization. An interview was conducted with the Administrator / DON on 08.12.2026 at 11:15 AM via telephone (as the Administrator / DON was out of the country at a memorial service for her late husband.) TheS surveyor reviewed the clinical record findings, agency admission packet, and findings of the home visits including the lack of the required privacy notices regarding OASIS collection of the patients. The surveyor asked who was responsible for the contents of the admission folders and information provided to the patients upon admission. The Administrator/DON stated she was responsible and put the packets together when she went out to admit the patients and stated, “staff must have misplaced it.” The Administrator / DON stated she understood what was required and that the agency “had fallen short.” Review of the agency policy titled, “Patient Bill of Rights and Responsibilities … RI 1 last reviewed “020110” read in part, “To ensure all patient/caregivers and Agency staff acknowledge, observe and implement the patient’s rights and responsibilities. Agency will provide information regarding the Patient Bill or Rights and Responsibilities … both verbally and in writing… to all Agency staff and each patient or legal guardian in advance of furnishing care or during the initial evaluation visit before the initiation of treatments … Agency staff will be responsible for knowing, observing, and implementing the patient’s rights and responsibilities on an ongoing basis… To participate in the selection of options for alternative levels of care or referral to other organizations, as indicated by the client/patient’s need for continuing care…To be advised of the availability, purpose and appropriate use of State, Medicare and … hotline numbers…””

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure the comprehensive assessment for 4 (#1, #2, #3, #4) of 4 active patients accurately reflected the patient’s status, and the comprehensive assessments failed to include patient’s current health, psychosocial (screening the patient’s relationships and living environment for how those circumstances affect delivery of services and the patient’s ability to participate in their own care), functional (the patient’s level of ability to function independently in the home), and cognitive status (an evaluation of the degree to which the patient can understand, remember, and participate in developing and implementing the plan of care. This failure meant the patients were at risk of an unsafe, ineffective, and inadequate plan of care. Record review of Patient #1’s comprehensive assessment signed by the Administrator / DON dated 08.07.2026 for the certification period 08.08.2026 to 10.06.2026 revealed no documentation of a wound, no orders for wound care, documentation the patient took more than 5 medications, but no medications were listed in the comprehensive assessment. The assessment contained no information about supportive assistance, no wound measurements, and no discharge plan. SN notes were documented three times per week in the clinical record for the certification period 08.08.2026 to 10.06.2026 with wound care documented as being provided. The assessment documented diagnoses of Diabetes Mellitus Type 2 with Foot Ulcer (blood sugar metabolism disorder with open wound on the foot), Type 2 Diabetes Mellitus with Diabetic Neuropathy (nerve damage from blood sugar metabolism disorder), and Hypertension (high blood pressure). The comprehensive assessment did not include documentation of psychosocial, functional, cognitive, and current health status. Observation and interview during a home visit on 08.11.2026 at 1:02 PM with Patient #1 revealed the patient wore a medical boot on their Lt foot. Patient #4 stated he had a wound on his Lt foot that was healing and he received wound care services during nursing visits by the agency several times per week. Record review of Patient #2s comprehensive assessment signed by the Administrator / DON dated 04.22.2026 at the start of care and another comprehensive assessment dated 06.24.2026 (reassessment) revealed no assessment of mental status, pain, fall risk assessment, coordination of care with other providers, no discharge plan, no medications, and no rehabilitation potential. These areas were left blank on both assessments. The assessment documented diagnoses of Diabetes Mellitus Type 2 (blood sugar metabolism disorder), Chronic Ischemic Health Disease (long term condition where the heart muscle does not get enough oxygen rich blood), and Hypertension (high blood pressure), Bilateral Primary Osteoarthritis of Knee (long term wear and tear arthritis of both knees), Mixed Hyperlipidemia (high blood fat levels), Age Related Cognitive Decline (slowdown of brain functioning as a person ages), Abnormalities of Gait and Mobility (problems with walking and balance), Ileostomy Status (surgically created opening in the abdomen where the small intestine is brought through the skin where waste leaves the body through the opening and collects in a pouch worn over the opening.) The comprehensive assessment did not include documentation of psychosocial, functional, cognitive, and current health status. Observation and interview during a home visit on 08.11.2026 at noon with Patient #2 and their family member (on the phone) revealed the patient was confused and needed assistance with ambulation. Patient #2 had a homemaker in the home during the visit provided by the agency. The Patient and family member stated the patient received PT services, homemaker services, and had received skilled nursing visits in the past for ileostomy and groin redness (red, irritated skin in the area where the upper thighs meet the lower abdomen/pelvic area) care. Review of Patient #3s comprehensive assessment signed by the Administrator / DON dated 07.14.2026 for the start of care revealed no assessment of medications with documentation of the patient taking 5 or more medications and both heart and kidney post-transplant status. The assessment documented no information about supportive assistance, pain assessment, genitourinary tract (refers to kidneys, blader, and urethra) or gastrointestinal tract (esophagus, stomach, digestive organs, and elimination organs). The assessment documented no information on the cardiovascular system (heart function, veins and arteries). The assessment documented no information on nutritional status or risks, no safety measures, interventions or goals, no medication goals, no coordination of care, no rehabilitation potential, and no discharge plan. The comprehensive assessment did not include documentation of psychosocial, functional, cognitive, and current health status. Observation and interview during an attempted home visit and telephone call on 08.11.2026 at 1:17 PM with Patient #3 revealed the patient was in a robe, stated he was feeling sick to his stomach that day, and needed to speak by telephone so he could be near his bathroom. Patient #3 stated he received PT and homemaker services and no skilled nursing services from the agency. Review of Patient #4s comprehensive assessment signed by the signed by the Administrator / DON dated 07.21.2026 for the start of care revealed no assessment of medications with documentation of taking 5 or more medications and a diagnosis of Diabetes mellitus with hyperglycemia and kidney disease (blood sugar disorder with high blood sugars and injury to the kidneys) and Hypertension (high blood pressure.) The assessment documented no information about supportive assistance, gastrointestinal tract (esophagus, stomach, digestive organs, and elimination organs). The assessment documented no information on the cardiovascular system (heart function, veins and arteries). The assessment documented no information on current blood sugar level, no safety measures, interventions or goals, no medication goals, no coordination of care, no rehabilitation potential, and no discharge plans. The comprehensive assessment did not include documentation of psychosocial, functional, cognitive, and current health status. An interview was conducted with the Administrator / DON on 08.12.2026 at 11:12 AM via telephone (as the Administrator / DON was out of the country). The Surveyor reviewed the clinical record findings including the incomplete areas on the comprehensive assessments of the patients. The Surveyor asked who was responsible for the contents of the comprehensive assessments. The Administrator/DON stated she was responsible. The Administrator / DON stated she did the assessments, entered the information into the electronic medical record, encoded, reviewed and transmitted comprehensive assessments for all the patients. The Surveyor asked why there were so many blank areas in the assessments- medications, nutritional status, psychosocial, functional, cognitive and current health status. The Administrator / DON stated: “That’s probably because I entered the ones I felt I didn’t have answers for. I use the VA doctor’s orders for information about medications and diet.” The DON stated that she didn’t use the agency’s electronic medical record to generate the plans of care. The DON stated: “I write my own.” The Surveyor asked about the agency policy and procedures for comprehensive assessments. The DON stated the policy requires all areas to be answered. The Surveyor asked about the blank areas noted for each patient. The DON stated she didn’t answer the new assessment questions as she used an older paper version of the assessment during the visit that didn’t have the new items. Agency policy titled “Patient Assessment Guidelines PE.2” dated “Rvd. 110102” read in part: “Agency will utilize and adhere to a defined comprehensive assessment in order to identify the patient’s needs for home care and that meets the patient’s medical, nursing, rehabilitative, social and discharge planning needs… Qualified Agency professionals who have the necessary skills and training and comply with all federal and state laws and regulations, will perform applicable initial assessments per discipline, as ordered by a physician…” Agency policy titled “Initial Patient Comprehensive Assessment PE.3” dated “Rvd. 110101” read in part: “Each patient will receive a patient specific, comprehensive assessment, that incorporates OASIS data set … The assessment will accurately reflect the patient’s current health status and assist in uniformly and consistently measuring patient outcomes…The Comprehensive assessment will include but not be limited to the following: Physical assessment/Review of systems, OASIS data set for Medicare / Medicaid patients which would include pertinent diagnoses, prognosis, physical findings … Medication history, including drug allergies, sensitivities and past adverse drug reactions … Residential environment, Nutritional requirements… all medications and past medication compliance history, Patient’s family or support system and the care they are capable of providing and willing to provide … Identifying patients who are at moderate or high nutritional risk … Incorporate the exact use of the current version of the OASIS data set for Medicare/ Medicaid patients…””