Good Samaritan Home Health 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 transmit each completed (OASIS) assessment to the (CMS) system regarding each beneficiary, within 30 days of completing the OASIS assessment of the beneficiaries five (Patients # 1, 2, 3, 4 and 5) of five patient assessments reviewed, in that; For report period 10/15/2023 to 10/15/2024 (36 %) of OASIS assessments had submission dates that were more than 30 days after the M0090 date (date OASIS assessment completed). The failure prevented the patients’ data from being available to CMS for timely analysis to identify agency performance levels in the provision of patient care and treatment. Findings included: Review of iQIES (Internet Quality Improvement & Evaluation System) on 10/15/2024 revealed the Agency’s OASIS error summary report for the report period of 10/15/2023 to 10/15/2024. Review of the report revealed the following: error description “Record Submitted Late: The submission date was more than 30 days after the M0090 date on this new record; [The number] of assessments processed 25; [The number] of assessments with error 9 [and the percentage] of assessment with error [26 percent].” Continued review of iQIES revealed the agency’s “OASIS Agency Final Validation” Report for report period of 10/16/2023 to 10/15/2024. Review of the report revealed that the agency submitted 9 of 25 OASIS assessments for Patients # 1 through 5 late (more than 30 days after the M0090 date). The late assessments included the following: A recertification OASIS assessment for Client # 4 was submitted on 11/07/2023 with a Moo90 date of 10/07/2023. A duplicate assessment for Client # 4 was submitted on 03/04/2024 with a M0090 date of 12/07/2023. A recertification OASIS assessment for Client # 5 was submitted on 02/05/2024 with a Moo90 date of 01/05/2024. A recertification OASIS assessment for Client # 3 was submitted on 02/16/2024 with a Moo90 date of 01/16/2024. A transfer to inpatient facility with discharge from agency OASIS assessment for Client # 5 was submitted on 04/02/2024 with a M0090 date of 03/02/2024. A recertification OASIS assessment for Client # 3 was submitted on 04/16/2024 with a Moo90 date of 03/16/2024. A recertification OASIS assessment for Client # 2 was submitted on 06/06/2024 with a Moo90 date of 05/03/2024. A transfer to inpatient facility with discharge from agency OASIS assessment for Client # 3 was submitted on 06/12/2024 with a M0090 date of 04/23/2024. A recertification OASIS assessment for Client # 1 was submitted on 07/17/2024 with a Moo90 date of 06/01/2024. During an interview with the Admin on 10/18/2024 at 3:09 p.m., the surveyor asked who at the agency was responsible for submitting the agency’s OASIS assessments. The Admin state that [the Admin] and the office Mgr. was responsible. The surveyor asked what the agency’s process was for submitting the agency’s OASIS assessments. The Admin stated that when the OASIS assessments were completed the agency submitted the assessments in 30 days or less. The surveyor reviewed the findings and asked why the OASIS assessments not submitted timely (within 30 days of the completion date). The Admin stated that “a few times we had a problem with the system. Sometimes it was an oversight.” The Surveyor asked if the Admin was aware of the percentage of the late submissions. The Admin replied, “I didn’t know there was that many.” Review of the Centers for Medicare and Medicaid Services website at, https://www.cms.gov/medicare/quality/home-health/oasis, on 10/25/2024 revealed that, “…The Outcome and Assessment Information Set (OASIS) is a group of standard data elements home health agencies (HHAs) integrate into their comprehensive assessment, to collect and report quality data to the Centers for Medicare & Medicaid Services (CMS)…The M0090 date 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 responses was completed…””

“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 and document PIP(s), for three (2021, 2022, and 2023) of three years reviewed, that reflected the scope, complexity and past performance of the agency’s services and operations. The failure placed the agency’s patients’ health and safety at risk if the agency did not identify and improve quality of care and service related to health and safety concerns. Findings included: On 10/15/2024 during the entrance conference with the Admin at 12:25 p.m., the surveyor provided an agency request list, which included a request for all agency QAPI records (reports, binders, and documents). Review of agency’s QAPI binder dated 2021, 2022, 2023, and 2024 revealed the following: A Performance Improvement Project was dated 02/16/2024. Continued review of the QAPI records did not reveal any documentation that indicated the agency had: any quality improvement projects undertaken, (in development, ongoing, or completed) the reason for conducting the projects, and the measurable progress achieved on the projects for each calendar year of 2021, 2022, and 2023. During an interview on 10/18/2024 approximately 3:15 p.m. with the Admin, the surveyor asked who was responsible for the agency’s QAPI program. The Admin stated that (the Admin) was responsible for the program, but also received input from “our team.” The surveyor asked what the agency’s processes were for its performance improvement projects. The Admin stated that the agency looked at the agency’s whole operation, guidelines, and areas where the agency might be falling behind; so that the agency can look at how to make improvements. She further stated “Like, if we are having late OASIS submissions, so that we can develop an area to focus.” The surveyor asked why the agency had not conducted and documented project improvement projects for the years 2021, 2022, and 2023. The Admin stated that “Maybe, we missed it [missed printing it]. The surveyor asked how the failure could adversely affect the agency’s patients. The Admin replied, “It will affect the quality of care. It is always good to have a plan.” The Admin also stated that the failure would probably affect patient care outcomes. Review of agency policy titled; “Quality Assessment Performance Improvement” dated 2022 revealed the following: “…Performance Improvement Projects: I. The agency must conduct performance improvement (PI) projects beginning July 13, 2018. II...A. At least one performance improvement project must be in development, on-going, or completed each calendar year...III. The agency must document the quality improvement projects undertaken, reason for conducting these projects and the measurable progress achieved...XII...QAPI documents will be...made available to HHSC staff upon request...””