Star Home Health

“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 electronically transmit the completed Outcome and Assessment Information Set (OASIS) assessment for 1 (patient #4) of 4 records reviewed to the state agency within 30 days of completing the OASIS assessment of the patient. Failure of the agency to transmit OASIS data within the required time frame prevented the agency’s patient data from being made available to Centers for Medicare & Medicaid Services (CMS) for analysis to identify agency performance levels in the provision of patient care. Findings: The surveyor reviewed the OASIS transmission report for the agency on the Internet Quality Improvement and Evaluation System (IQIES an internet-based system that includes survey and certification functions) portal on 11/25/2024, as part of the preparation for the survey. In an interview with the Office Manager on 11/25/2024 at approximately 10:10 AM, the surveyor requested the Centers for Medicare & Medicaid Services (CMS) OASIS Agency Final Validation report for the last 12 months and asked who was responsible for the Oasis transmissions. The Office Manager said, “I’m responsible for the Oasis transmissions.” The surveyor reviewed the OASIS Agency Final Validation report provided by the Office Manager on 11/26/2024. The agency Oasis Agency Final Validation report documented: 1) Patient #4 was admitted to the agency effective 08/06/2024 and remained an active patient as of 11/26/2024. The report documented the date of the Admission Assessment as entered by the agency at OASIS assessment item M0090 was 08/06/2024. The report documented the submission date of the admission was 11/24/2024. The report documented the following error message: “Record submitted late: The submission date is more than 30 days after M0090 (Oasis coding used to determine the last date that information used to complete the assessment completed) on this new record.” An interview was conducted with the Office Manager and Alternate Administrator/Director of Nursing on 11/26/2024 at 2:50 PM. The surveyor reviewed the Centers for Medicare & Medicaid Services (CMS) OASIS Agency Final Validation report provided the agency with the Office Manager and Alternate Administrator/Director of Nursing. The surveyor reviewed the findings of the late transmission of the assessment for patient # 1. The surveyor asked why the Oasis were transmitted late by the agency. The Office Manager stated, “I got distracted. It was an oversight.””

“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 interview and record review, the agency failed to develop, implement, and evaluate performance improvement projects for 3 of 3 (2021, 2022, and 2023) years reviewed. This failure could have resulted in the agency failing to identify and address areas of the agency’s program for which performance could be improved. The findings included: On 11/27/24 reviewed of the QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN (QAPI) documentation regarding the agency’s Quality Assessment Performance Improvement Plan (QAPI) Program included no documentation to indicate the agency had developed, implemented, or evaluated a performance improvement project for the years 2021, 2022, and 2023. During an interview with the Alternate Administrator on 11/27/2024 at approximately 11:55 AM the surveyor presented the above findings. The surveyor asked who was responsible for the agency QAPI program and committee meetings. The Alternate Administrator stated, “Me and the Administrator. The performance improvement projects were an oversight on our part.” Review of agency policy, dated 050124, quoted in part, “QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PROGRAM QAPI.5, read in part” .... E. Performance Improvement Projects 1. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency’s services and operations…QAPI documents will be kept confidential and will be made available to State Home Health licensing agency staff on request...””