A-Unified Home Health Agency, 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 ensure that the completed OASIS assessments were electronically transmitted to the Internet Quality Improvement Evaluation System within 30 days of the comprehensive patient assessment being finalized for 22.5% of patient records entered between the dates of 5/1/2025-5/13/2026. This failure meant patients were subjected to the potential for poor quality of care. Review of the IQIES HHA Error Summary by Agency Report for the dates – 5.1.2025-5.13.2026 which was ran on 5/13/2026 resulted in the error -3330, Record Submission Late: The submission date is more than 30 days after M0090 [comprehensive patient assessment date] on this new record, # of assessments with error is (9) - resulting in a 22.5% error rate. During an interview with the Administrator on 5/13/2026 at 3pm the Surveyor asked what the process is for OASIS encoding and transmission and who was responsible for ensuring the OASIS was transmitted in a timely manner. The Administrator reported that he was responsible for transmitting all the OASIS data within 30 days of admission after the Director of Nursing reviewed the assessments. He reported that his computer system was not working from November 2025 to February 2026. The Surveyor asked if there was any back-up plan and he reported the situation to the OASIS Service Desk and he did not report or contact them. Review of the agency policy titled, “Timelines,” dated, 01/13/2018, read in part, “…all completed and encoded OASIS data…will be transmitted using electronic communications software…within thirty (30) days of the M00900 [admission] date.””

“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, interview, and record review, the agency failed to ensure patients were advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patients 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 for 2 of 2 patient’s (#1, #2) who completed home visits with the surveyor and had a home folder. The agency did not follow policy to ensure the patients had the required numbers as required by regulation, placing clients at risk of receiving inadequate care, and including the information to request an expedited review of changes in services provided by the agency. This failure meant the patients’ rights were violated to ensure access to services as needed and placing clients at risk of receiving inadequate care. The surveyor requested a sample admission packet with all documents provided to the patients of the agency during the entrance conference on 05.13.2026 at 12PM. Record review of the sample admission packet 5.13.2026 at 3pm, provided by the Administrator revealed a resource list dated 01.01.2016 which failed to include the required Federally funded and state-funded entities. The list did not include the names, addresses, and telephone numbers for the following: (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. Interview and record review on 05.15.2026 at 12:30 pm during home visit of Patient #1 revealed no list of the required Federally funded and state-funded entities that included the names, addresses, and telephone numbers for the following: (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 in the home folder provided by the agency during admission. The Surveyor observed that there were two sheets with emergency and resource numbers which matched the same forms from the sample packet reviewed at the agency, but the following numbers were not included: 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. Interview and record review on 05.15.2026 at 2 pm during home visit of Patient #2 revealed no list of the required Federally funded and state-funded entities that included the names, addresses, and telephone numbers for the following: (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 in the home folder provided by the agency during admission. The surveyor asked if the patient had removed any items from the home folder and Patient #2 stated he had not removed anything and had not been provided with a list of resources other than what was in the home folder. An interview was conducted on 05.19.2026 at 12 pm with the Administrator. The Administrator reported that the administrative office manager was responsible for printing and putting the home admission packets together. The Administrator reported that he was responsible for ensuring all the policies of the agency were implemented and that the required information was given to the patients. Record review of the agency’s policy, titled, “Patient/Client Rights and Responsibilities, Right of the Elderly,” page RI.2, Section K, dated, 1/01/2018, read in part, “…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 / client resides: 1. Agency on Aging, 2. Center for Independent Living, 3. Protection and Advocacy Agency, 4. Aging and Disability Resource Center, 5. Quality Improvement Organization.”