Guidance Healthcare Services

“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 (a tool used by CMS to collect certain patient information) assessment to CMS within 30 days of completing the OASIS assessment, in that: from 09/01/2024 to 03/06/2025 there were 9 assessments transmitted greater than 30 days from the assessment completion date. This Failure prevented the agency’s patient data from being made available to CMS for analysis to identify agency performance levels in the provision of patient care. Pre-survey review of the report titled, “OASIS Error Detail Report” taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed 9 (patients 1, 2, 4, 5 and 6) assessments contained error number -3330 with the error message of, “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” On 03/14/2025 at approximately 10:42 AM the surveyor conducted an interview with the Administrator. The surveyor discussed the OASIS report titled, “OASIS Error Detail Report.” The surveyor explained that from 09/01/2024 to 03/06/2025 the agency transmitted 9 OASIS greater than 30 days from the completion date (M0090) to CMS. The surveyor asked who was responsible for transmitting the OASIS assessment to CMS. The Administrator stated, “I do” The surveyor asked if the agency tracked how long it took for an OASIS to be transmitted to CMS. The Administrator stated, “I always send them in when I get it done” The surveyor asked why the agency had 9 OASIS assessment that were transmitted past 30 days to CMS. The Administrator stated, “I think we do not get back all the doctors to sign an then we can’t submit them until the doctor sign everything and we get it back to make sure the OASIS is accurate.” The surveyor asked how often the agency transmitted OASIS assessments to CMS. The Administrator stated, “I just submit them when I get them done.” Record review for Patient 1: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 64077092 submission date 11/08/2024 with 2 total record processed. Record 1 (Patient 1) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 1 (Patient 1) of the OASIS Agency Final Validation report that was submitted on 11/08/2024 had a M0090 completion date of 10/06/2024. Record review for Patient 2: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed two late submissions during record review. The first late submission was identification number 63939840 submission date 10/11/2024 with 1 total record processed. Record 1 (Patient 2) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 1 (Patient 2) of the OASIS Agency Final Validation report that was submitted on 10/11/2024 had a M0090 completion date of 08/05/2024. The second late submission was identification number 64180774 submission date 12/02/2024 with 2 total records processed. Record 1 (Patient 2) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 1 (Patient 2) of the OASIS Agency Final Validation report that was submitted on 12/02/2024 had a M0090 completion date of 10/03/2024. Record review for Patient 4: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 64104199 submission date 11/14/2024 with 2 total records processed. Record 1 (Patient 4) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 1 (Patient 4) of the OASIS Agency Final Validation report that was submitted on 11/14/2024 had a M0090 completion date of 08/29/2024. Record review for Patient 5: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 63915743 submission date 10/07/2024 with 1 total records processed. Record 1 (Patient 5) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 1 (Patient 5) of the OASIS Agency Final Validation report that was submitted on 10/07/2024 had a M0090 completion date of 08/01/2024. Record review for Patient 6: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 64180774 submission date 12/02/2024 with 2 total records processed. Record 2 (Patient 6) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 2 (Patient 6) of the OASIS Agency Final Validation report that was submitted on 12/02/2024 had a M0090 completion date of 09/12/2024. On 03/19/2025 at approximately 9:15 AM the surveyor conducted an interview with the Administrator. The surveyor discussed the findings from the patient record reviews. The surveyor explained that during record review he found Patients 1, 2, 4, 5 and 6 had OASIS that were transmitted to CMS more than 30 days after the M0090 dates. The surveyor asked why the OASIS were transmitted past 30 days. The Administrator stated, “I think again it is because we do not have everything back from the doctor to make sure the OASIS matches the face to face.” The surveyor asked how the failure to submit the OASIS to CMS within 30 days could effect the clients services. The Administrator stated, “I don’t know if it would do that.” Review of Agency policy titled, “Timelines” with a revision date of 10/25/2024 read in part: “…II. All completed and encoded OASIS data will be transmitted…from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date.””