Aaa Home Healthcare

“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 09/01/2023 to 10/28/2024 there were 167 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. 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 09/01/2023 to 10/28/2024 there were 167 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. Findings included: Pre-survey review of the report titled, “OASIS Error Detail Report” taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed 167 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 10/30/2024 at approximately 2:15 PM the surveyor conducted an interview with the Administrator, Human Resource Manager, and RN J. The surveyor discussed the OASIS report titled, “OASIS Error Detail Report.” The surveyor explained that from 09/01/2023 to 10/28/2024 the agency transmitted 167 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, “the human resource manager (Employee I). The surveyor asked if the agency tracked how long it took for an OASIS to be transmitted to CMS. The Human resource manager (Employee I) stated, “We try to get it in within 24 hours but no later than 30 days” The surveyor asked why 167 OASIS assessment were transmitted past 30 days to CMS. The Administrator stated, “I can’t believe we had that many late ones I didn’t think we even had that many patients.” The surveyor asked the Human Resource Manager (Employee I) what he thought caused the agency to have late OASIS assessment submissions to CMS. The Human Resource Manager (Employee I) stated, “Sometime we have to wait on the doctor for the billing to make sure that the OASIS has the correct doctor or maybe with the nurses” The surveyor asked how often the agency transmitted OASIS assessments to CMS. The Human Resource Manager (Employee I) stated, “We submit when we get them. I will submit them. I don’t wait when I have one to submit I will transmit it” 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 62490607 submission date 12/03/2023 with 4 total records processed. Record 1 (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 1 (Patient 6) of the OASIS Agency Final Validation report that was submitted on 12/03/2023 had a M0090 completion date of 10/20/2023. Record review for Patient 7: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 62460447 submission date 11/27/2023 with 35 total record processed. Record 10 (Patient 7) 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 10 (Patient 7) of the OASIS Agency Final Validation report that was submitted on 11/27/2023 had a M0090 completion date of 10/19/2023. On 11/04/2024 at approximately 1:47 PM the surveyor conducted an interview with the Administrator, Alternate Administrator/Supervising Nurse, Alternate Supervising/Quality Assurance Nurse, Human resource manager and RN J. The surveyor reviewed the findings from the record review for patients 6 and 7. The surveyor explained that Patient 6 and 7 each had an OASIS transmittal that was past 30 days from the completion dates. The surveyor asked why Patients 6 and 7 had OASIS transmittals to CMS past 30 days from the completion date (M0090). The Alternate Supervising/Quality Assurance Nurse stated, “I’m not sure but maybe we didn’t have the login to be able to transmit but I don’t know.” The surveyor reviewed the OASIS late detail report and explained the agency had 167 OASIS assessments transmitted to CMS late. The surveyor asked why there were 167 late OASIS. The Alternate Supervising/Quality Assurance Nurse stated, “We identify that we were having problems with that. We have a plan to get better. We have been hiring more experienced staff and we have been doing education with the nurses and we hired another nurse to be in the office to help with making sure we are getting the OASIS assessments sent on time.” On 11/04/2024 at approximately 3:41 PM, the surveyor reviewed the preliminary findings with the Administrator, Alternate Administrator/Supervising Nurse, Alternate Supervising/Quality Assurance Nurse and RN J. The agency did not dispute the findings and did not provide any additional evidence to explain or correct the findings. Review of Agency policy titled, “TIMELINES IM.35” with a revision date of 05/02/2024 read in part: “II. All completed and encoded OASIS data will be transmitted via electronic communication software… within thirty (30) days of the M0090 date.””