Home Medical Care, 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 record review and interview the agency failed to encode and electronically submit each completed OASIS assessment (a tool used by CMS to collect certain patient information) to the CMS system within 30 days of completing the assessment of the beneficiary for 30 OASIS assessments submitted during 01/01/2024 to 12/31/2024 for 27 patients. This failure meant insufficient care could not be identified by the agency or CMS subjecting patients to inadequate continuity of care. Record review of the agency’s OASIS errors report in iQIES (a CMS data-based system for patient analysis of care trends) on 02/07/2025 which documented the agency had submitted 30 comprehensive assessments more than 30 days after the date of the assessment. The report listed 27 patient names as being affected by the late transmission of their comprehensive assessments from 01/01/2024 to 12/31/2024. In an interview with the Alternate Administrator on 02/12/2025 11:30 AM, the surveyor inquired about the OASIS assessment transmission being late. The Alternate Administrator stated he was responsible for the transmission entries and sending the assessments, but time got away. The alternate Administrator stated he reports the errors to the Administrator and the DON for communications. The Alternate Administrator stated he does all the OASIS transmissions, no other employee does. The surveyor showed the Alternate Administrator the iQIES M0090 3330 error report run on 02/07/2025 which showed the 30 errors and list of 27 patient names. Alternate Administrator agreed it was accurate and did not dispute. The alternate verbalized understanding of the report. In an interview with the Administrator 02/12/2025 12:20 PM, it was revealed the administrator was aware of the M0090 3330 iQIES error report of late OASIS submissions. The administrator stated the Alternate Administrator met with him about it “from time to time”. The Administrator stated it is the Alternate Administrator that enters the OASIS submissions, but ultimately it is the Administrators responsibility. The Administrator looked at the report ran on 02/07/2025 that revealed the M0090 3330 iQIES error report and agreed with the report. Record review of the agency’s policy dated 10/25/2024, Administrative Policy Manual, Health Care Consult Link quoted in part, “TIMELINES, IM.35, page 2 of 2 section II. All completed and encoded OASIS data will be transmitted via electronic communication software that is available from CMS or software that conforms to CMS electronic record layout, edit specifications, and data dictionary, and that includes the required OASIS data set and the CMS assigned branch identification number, as applicable. It will be transmitted using electronic communications software that complies with the Federal Information Processing Standard from the agency or agency contractor to the CMS collection site within 30 days of the M0090 date”.”

“Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to maintain a Quality Improvement/Performance Improvement Program to measure, review, and track quality indicators, including a representative sample of services furnished in both active and discharged records, a determination that services have been performed as outlined in the individualized services, and other aspects of performance that would enable the agency to assess outcomes that are measurable and have a written plan of implementation for three of the three-year period of review (02/23/2022 to 02/18/2025). This failure caused the agency to have no effective mechanism to monitor, evaluate or improve plan of care, continuity of care and services to agency clients. The surveyor requested the QAPI program documents during the survey on 02/12/2025 at 1:30 PM. A record review of QAPI Binder documents provided by the Alternate Administrator on revealed: There was iQIES report printouts that were in binder categories for QAPI. There were QAPI plans that were not filled out. There was no evidence of completed QAPI activities for 02/23/2022 to 02/23/2023, 02/23/2023 to 02/23/2024 or 02/23/2024 to 02/18/2025. There were no samples of auditing services furnished to clients in active and discharged charts. In an interview with the Alternate Administrator on 02/12/2025 at 2:30 PM, the surveyor reviewed the binders that were provided and asked the Alternate Administrator about the agency’s lack of QAPI documented activities. The Alternate Administrator stated, after the last survey they attempted to cut costs by terminating consultant services. The consultant usually assisted in conducting meetings, interviews and review of iQIES report print outs for us. The alternate administrator stated, we (Administrator, Alternate Administrator, DON, Office Manager and Physical Therapist) printed out the iQIES reports and verbally discussed the reports and recommended actions but did not keep records. The surveyor asked the Alternate Administrator if he could provide any documents at this time that could be considered meeting records or committee records. The Alternate Administrator stated, he could not. The surveyor asked the Alternate Administrator who was responsible for reviewing the agency’s QAPI activities. The Alternate Administrator stated he and ultimately the Administrator was responsible for reviewing the QAPI activities. In an Interview with the Administrator on 02/18/2025 11:15 AM the surveyor asked the Administrator about the agency’s QAPI binder filled with iQIES reports and lack of QAPI documented activities. The Administrator stated, they have ongoing discussions and have meetings twice a year. The surveyor asked the Administrator if he could provide documentation of the meeting discussions. The Administrator said he could not. The administrator stated the QAPI was usually handled by the Alternate Administrator and the consultant with the committee team members. The administrator stated he was aware it is the Administrators ultimate responsibility for all QAPI activities. In an Interview with the DON on 02/18/2025 12:45 PM the surveyor asked the DON as a QAPI committee member about the agency’s QAPI binder filled with iQIES reports and lack of QAPI documented activities. The DON stated, she is not sure what always goes in the binder, but they meet in the office and have verbal conversations sometimes monthly. The surveyor asked the DON if she could provide documentation of the meeting discussions. The DON said she could not. Administrative Policy Manual Home Care Performance Improvement Process: Agency policy provided by, Health Care Consult Link, quoted in part, Administrative Policy Manual Home Care Performance Improvement Process: Data Collection QAPI.5 Page 1 of 4 dated 05/01/2024. Quoted in part… “Purpose: To develop, Implement, evaluate, and maintain an effective, ongoing, Agency-wide, data-driven Quality Assessment Performance Improvement (QAPI) Program as defined by its QAPI Plan…. Data is collected to monitor the stability of existing processes, identify opportunities for improvement, identify changes that will lead to improvement, and sustain improvement.””

“Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA’s services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to conduct performance improvement projects annually for three of the three-year periods of review (02/22/2022 to 02/18/2025). This failure potentially subjected patients to substandard care when the agency had not evaluated the care and operations and developed plans to improve performance, and or address any issues that were or could have impacted patient care. The surveyor requested the PIP program documents during the survey on 02/12/2025 1:30 PM. A review of documents provided by the Alternate Administrator on revealed QA and PI binder revealed no Professional Advisory Committee meetings documented. No evidence of performance improvement projects for 02/23/2022 to 02/23/2023, 02/23/2023 to 02/23/2024 or 02/23/2024 to 02/18/2025 was provided. In an interview with the Alternate Administrator on 02/12/2025 at 2:30 PM, the surveyor reviewed the findings and asked about the lack of Performance Improvement Projects. The Alternate Administrator stated, after the last survey they attempted to cut costs by terminating consultant services. The consultant usually assisted in conducting meetings, interviews and review for Performance Improvement. The alternate administrator stated, “we verbally discussed the reports and recommended actions, but did not keep records”. The Alternate Administrator stated he responsible for completing the Performance Improvement Projects, but ultimately the Administrator is responsible. In an Interview with the Administrator on 02/18/2025 11:30 AM the surveyor asked the Administrator about the agency’s Performance Improvement Projects. The Administrator stated, they have ongoing discussions and have meetings about Performance Improvement. The surveyor asked the Administrator if he could provide documentation of the meeting discussions. The Administrator said he could not. The administrator stated the Performance Improvement was usually handled by the Alternate Administrator and the consultant. The administrator stated he was aware it is the Administrators ultimate responsibility for all Performance Improvement Projects. Record review of Agency Policy, quoted in part, dated 070711, “PERFORMANCE IMPROVEMENT PROCESS… page 1 of 2 QAPI.3, PURPOSE: Quoted in part … “Data is collected to monitor the stability of existing processes, identify opportunities for improvement, identify changes that will lead to improvement, and sustain improvement. POLICY: The Agency will collect data to monitor performance of areas targeted for study and to determine effectiveness of the change….””