Mga Home Health Plus 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 15 of 131 OASIS assessments transmitted between 10/24/2023 to 10/25/2024. 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 (CMS) OASIS-E (Outcome and Assessment Information Set - tool used by CMS to collect patient information to measure outcomes and quality improvement) Guidance Manual, updated 1/1/2024, 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 10/25/2024 indicated that 15 assessments contained the error number -3330, which indicated that the OASIS Assessments were submitted more than 30 days after the assessment completion date between 10/24/2023 and 10/25/2024. Review of the agency’s “OASIS Agency Final Validation” report taken from the Internet Quality Improvement and Evaluation System on 10/25/2024 indicated that the agency submitted 131 OASIS assessments between 10/24/2023 to 10/25/2024. During an interview on 10/30/2024 at approximately 12:50 p.m. with the Administrator, Supervising Nurse, and the Quality Assurance Reviewer, the surveyor discussed the OASIS Error Detail Report; the report indicated that the agency had 15 OASIS assessments that were transmitted to the CMS system more than 30 days after the OASIS assessments had been completed. The surveyor asked why the OASIS assessments were transmitted late and what the OASIS assessment transmissions process was. The Administrator informed the surveyor that they used (software). The surveyor asked when the agency transmitted the OASIS assessments. The Administrator stated, “As soon as the OASIS comes through the system. The surveyor asked who was responsible for completing the OASIS assessments. The Administrator informed the surveyor that the Supervising Nurse would be responsible for completing the assessments. The surveyor asked what was the time frame that the agency required that OASIS assessment be turned in to the agency. The Supervising Nurse stated, “Within 3 days, 5 days maximum.” The surveyor asked what the next step was after the OASIS assessment had been turned into the agency by the clinician. The Supervising Nurse informed the surveyor that the Quality Assurance Reviewer would sometimes review, but not all the time. The Quality Assurance Reviewer informed the surveyor that the OASIS would be sent to be pre-approved to another agency, Review Agency. Review Agency would send the OASIS back. The Quality Assurance Reviewer informed the surveyor that sometimes the Review Agency would send it back because the Review Agency could not see all the pages. The Review Agency would send it back to the agency. The agency would send whatever the Review Agency returned. The Administrator informed the surveyor that the agency used the pre-approved method with CMS and the agency would send everything to Review Agency. The surveyor asked who would receive the OASIS when it came back to the agency from the review agency. The Administrator stated that it would go to Quality Assurance Reviewer and then it would go into the Administrator’s “hot Box”(in the software System) when it was ready for the Administrator to transmit. The Administrator stated, “I did not know there were more than a couple that were late.” Review of the agency’s policy titled “Timelines,” labeled IM.35,” and last revised on 5/02/2024. 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 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 (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...””