M & L Medical 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 record review and interview, the agency failed to transmit completed OASIS assessments (Outcome and Assessment Information Set - used to collect patient information to measure outcomes and quality improvement) within 30 days of completing the OASIS assessments to the Centers for Medicare & Medicaid Services (CMS) system for 19 of 36 OASIS assessments transmitted between 6/1/2023 to 5/31/2024. The failure made the agency’s data unavailable to the Centers for Medicare & Medicaid Services to evaluate the agency’s provision of patient care. Review of the Centers for Medicare and Medicaid Services OASIS-E Guidance Manual (updated January 1, 2024) read in part; “Chapter 1: OASIS Guidance Manual Introduction…1.5.5.1 General OASIS Item Conventions…14…M0090- Date Assessment Completed, is the last date that information used to complete the comprehensive assessment and determine OASIS coding was gathered by the assessing clinician and documentation of the specific information/responses was completed…” Review of the “OASIS Error Detail Report” taken from the Internet Quality Improvement and Evaluation System (IQIES) on 9/18/2024 indicated that 19 assessments contained the error number -3330, which indicated that the OASIS Assessments were submitted more than 30 days after the assessment completion date (M0090) between 6/1/2023 and 5/31/2024. Record review for Patient 1: Review of the OASIS Agency Final Validation report taken from IQIES revealed submission identification number 63234636, submitted on 5/14/2024 with three records submitted. Record 1 (Patient 1) indicated that the M0090 date was 4/11/2024. Record 1 listed the following error: “Message Number/Severity: - 3330 Warning, Message: Record submitted late: The submission date is more than 30 days after M0090 on this new record.” Record review for Patient 7: Review of the OASIS Agency Final Validation report taken from IQIES revealed submission identification number 63140645, submitted on 4/24/2024, with three records submitted. Record 3 (Patient 7) indicated that the M0090 date was 3/13/2024. Record 3 listed the following error: “Message Number/Severity: -3330 Warning, Message: Record submitted late: The submission date is more than 30 days after M00090 on this new record.” During an interview on 9/24/2024 at approximately 1:00 p.m. with the Administrator and Supervising Nurse, the surveyor discussed the OASIS Error Detail Report. The surveyor discussed that the report indicated that the agency had 19 OASIS assessments that were transmitted to the CMS system more than 30 days after the assessments had been completed. The surveyor asked why the OASIS assessment transmissions were late. The Administrator informed the surveyor that it was like “pulling teeth” to get the nurses to turn in the OASIS. The Supervising Nurse stated, “We call them and send them emails” about turning in the OASIS assessments. The surveyor asked what the agency’s process regarding OASIS assessments was. The Supervising Nurse informed the surveyor that the registered nurses have 48 hours to complete the OASIS assessment and give the assessment to the agency. After the OASIS assessment was turned in to the agency, quality assessment would approve it, and the nurse would sign it. The Administrator would then export the OASIS assessment. The surveyor asked who was responsible to track the OASIS to be turned in. The Supervising Nurse informed the surveyor that Employee D, (works in the office) would tract the OASIS. The surveyor asked what Employee D would do when it was noted that the OASIS assessments were not turned in within the agency’s timeframe. The Supervising Nurse stated that Employee D would call the nurse and text them. The Supervising Nurse would also call and text the nurses. The Supervising Nurse stated that the skilled nurses, “Know to turn it in.” The nurses would tell the agency that they would get them turned in. Employee D was on leave at the time of the survey. Review of the agency’s policy titled “Timelines,” labeled IM.7, and dated 8/1/2020. The policy read in part; “Purpose To establish timely parameters for all medical record information. 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...II. All completed and encoded OASIS data which accurately reflects the patient’s/client’s status at the time of the assessment, 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 date 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 (FIPS 140-2, issued May 25, 2001) from the Agency or the Agency contractor to the CMS collection site within thirty (30) days of the M0090 date...””