Bathfol Health 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 have a system in place to ensure that completed OASIS assessments were transmitted within 30 days of completing the assessments resulting in an error rate of 50.00% for the period 10/01/2025 - 08/11/2026. The Agency Validation reports from 08/11/2025 to 08/11/2026 showed the agency did not transmit up to 50% of the OASIS assessments within 30 days of completing the assessments for patients. Failure of the agency to transmit patients’ OASIS data within the federal guidelines can cause delay or deny the final claim payment for that service episode and can create administrative roadblocks in the patient’s continuum of care. Findings Review of the Federal database report titled, “CMS State Report: HHA Error Summary by Agency,” submitted for 10/01/2025 - 08/11/2026, showed an error rate for Error -3330 (inconsistent M0090 (assessment completed date/Submission Date) of 50%. The -3330-error message read in part: “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Review of the agency’s M0090 Final Validation Report dated 08/29/2025 showed that 1 record was processed and had the -3330 warning. M0090 date was 05/22/2025 and submission date was 08/29/2025. Totaling more than 90 days after M0090. Review of the agency’s M0090 Final Validation Report dated 01/05/2026 showed that 3 records were processed and 2 had the -3330 warning. M0090 date was 11/15/2025 and submission date was 12/16/2025. Record #1 – M0090 date was 12/02/2025 and submission date was 01/05/2026. Record #3 – M0090 date was 12/05/2025 and submission date was 01/05/2026. Review of the agency’s M0090 Final Validation Report dated 01/09/2026 showed that 1 record was processed and had the -3330 warning. M0090 date was 10/03/2025 and submission date was 01/09/2026. Totaling more than 90 days after M0090. Review of the agency’s M0090 Final Validation Report dated 01/09/2026 showed that 1 record was processed and had the -3330 warning. M0090 date was 11/15/2025 and submission date was 01/09/2026. Totaling more than 60 days after M0090. Review of the agency’s M0090 Final Validation Report dated 01/19/2026 showed that 3 records were processed and 2 had the -3330 warning. Record #2– M0090 date was 12/19/2025 and submission date was 01/19/2026. Record #3 – M0090 date was 12/17/2025 and submission date was 01/19/2026. Review of the agency’s M0090 Final Validation Report dated 02/26/2026 showed that 2 records were processed and 2 had the -3330 warning. Record #2– M0090 date was 11/25/2025 and submission date was 02/26/2026. Totaling more than 90 days after M0090. Review of the agency’s M0090 Final Validation Report dated 03/13/2026 showed that 1 record was processed and had the -3330 warning. M0090 date was 12/13/2025 and submission date was 03/13/2026. Totaling more than 90 days after M0090. Review of the agency’s M0090 Final Validation Report dated 03/16/2026 showed that 1 record was processed and had the -3330 warning. M0090 date was 12/13/2025 and submission date was 03/16/2026. Totaling more than 90 days after M0090. Review of the agency’s M0090 Final Validation Report dated 04/15/2026 showed that 2 records were processed and 2 had the -3330 warning. Record #2– M0090 date was 03/04/2026 and submission date was 04/15/2026. Totaling more than 30 days after M0090. Review of the agency’s M0090 Final Validation Report dated 05/19/2026 showed that 3 records were processed and all 3 had the -3330 warning. Record #1– M0090 date was 03/23/2026 and submission date was 05/19/2026. Totaling more than 60 days after M0090. Record #2– M0090 date was 03/14/2026 and submission date was 05/19/2026. Totaling more than 60 days after M0090. Record #3– M0090 date was 02/25/2026 and submission date was 05/19/2026. Totaling more than 60 days after M0090. Review of the agency’s M0090 Final Validation Report dated 05/27/2026 showed that 2 records were processed and 2 had the -3330 warning. Record #2– M0090 date was 03/29/2026 and submission date was 05/27/2026. Totaling more than 60 days after M0090. Review of the agency’s M0090 Final Validation Report dated 05/28/2026 showed that 2 records were processed and 1 had the -3330 warning. Record #1– M0090 date was 04/23/2026 and submission date was 05/27/2026. Totaling more than 60 days after M0090. Review of the agency’s M0090 Final Validation Report dated 06/18/2026 showed that 6 records were processed and all 6 records had the -3330 warning. Record #1– M0090 date was 04/22/2026 and submission date was 06/18/2026. Totaling more than 30 days after M0090. Record #2– M0090 date was 04/24/2026 and submission date was 06/18/2026. Totaling more than 30 days after M0090. Record #3– M0090 date was 04/03/2026 and submission date was 06/18/2026. Totaling more than 60 days after M0090. Record #4– M0090 date was 04/18/2026 and submission date was 06/18/2026. Totaling more than 60 days after M0090. Record #5 – M0090 date was 04/10/2026 and submission date was 06/18/2026. Totaling more than 60 days after M0090. Record #6– M0090 date was 04/17/2026 and submission date was 06/18/2026. Totaling more than 60 days after M0090. Review of the agency’s M0090 Final Validation Report dated 07/03/2026 showed that 3 records were processed and 3 had the -3330 warning. Record #1– M0090 date was 04/24/2026 and submission date was 07/03/2026. Totaling more than 60 days after M0090. Record #2– M0090 date was 04/21/2026 and submission date was 07/03/2026. Totaling more than 60 days after M0090. Record #3– M0090 date was 04/22/2026 and submission date was 07/03/2026. Totaling more than 60 days after M0090. Review of the agency’s M0090 Final Validation Report dated 07/08/2026 showed that 3 records were processed and 3 had the -3330 warning. Record #1– M0090 date was 05/04/2026 and submission date was 07/08/2026. Totaling more than 60 days after M0090. Record #2– M0090 date was 05/19/2026 and submission date was 07/08/2026. Totaling more than 60 days after M0090. Record #3– M0090 date was 05/07/2026 and submission date was 07/08/2026. Totaling more than 90 days after M0090. Review of the agency’s M0090 Final Validation Report dated 07/09/2026 showed that 3 records were processed and 3 had the -3330 warning. Record #1– M0090 date was 05/04/2026 and submission date was 07/09/2026. Totaling more than 60 days after M0090. Record #2– M0090 date was 05/19/2026 and submission date was 07/09/2026. Totaling more than 30 days after M0090. Record #3– M0090 date was 05/07/2026 and submission date was 07/09/2026. Totaling more than 60 days after M0090. Review of the agency’s M0090 Final Validation Report dated 08/10/2026 at 13:12 showed that 3 records were processed and 1 had the -3330 warning. Record #1– M0090 date was 07/09/2026 and submission date was 08/10/2026. Totaling more than 30 days after M0090. Review of the agency’s M0090 Final Validation Report dated 08/10/2026 at 13:13 showed that 3 records were processed and 1 had the -3330 warning. Record #1– M0090 date was 07/09/2026 and submission date was 08/10/2026. Totaling more than 30 days after M0090. During an interview on 08/13/2026 with the Alternate Administrator (AA) at 10:54a.m., The Surveyor asked AA who was responsible for OASIS data submission. AA stated that she was responsible for OASIS submission. Surveyor asked about the agency’s process for transmitting OASIS data and the time frame of submission following assessment completion dates. AA stated that it depends on when the nurses completed the OASIS and knew that the nurses are always delaying the process which prevented her from submitting within 30 days of completion. AA added that Adm/DON was aware and that AA’s responsibility was to follow Adm/DON’s recommendations. During interview on 08/13/2026 with Adm/DON and ADON at 11:55am on Agency process of OASIS transmission. ADON stated that the Adm/DON oversaw the nurses responsible for timely submission of OASIS to allow transmission within 30 days of M0090. Adm/DON stated that she was aware that the nurses put in their documentation of visits late and she herself had not caught up on the issues. Adm/DON stated further that the nurses are known for completing admission within 48 hours of the referral and have 5 days before the end of the certification period to conduct a recertification assessment. The Surveyor asked for the impact of not submitting OASIS data within 30days of assessment. ADON stated the impact on the patients could be Medicare keeping track of the Medicare bill on the amount the patient had incurred, amount that was left, the agency may not get paid and would lack the process of patient care goal if the agency does not stay in compliance with CMS rules. Review of the agency’s policy numbered 5.0.302 titled, “OASIS Compliance” read in part; “Procedure: XI. The Agency will encode and be capable of transmitting OASIS data for each agency Medicare/Medicaid patient within 7 days of completing an OASIS data set… The M090 date is day zero for calculating the seven days. XIII. The Agency will electronically transmit accurate, completed, encoded and locked OASIS data for each Medicare/Medicaid patient to the state agency or CMS… XIV. All assessments completed in the previous month shall be transmitted in a format specified by CMS.”