Avian 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 encode and electronically transmit each completed OASIS (Outcome and Assessment Information Set) assessment to the CMS system regarding each beneficiary (patient), within 30 days of completing the OASIS assessment of the beneficiaries in that; For report period 12/09/2024 to 12/09/2025 (80 of 102) 78.43 % of OASIS assessments had submission dates that were more than 30 days after the M0090 date (date OASIS assessment completed). The failure prevented the patients’ data from being available to CMS for timely analysis to identify agency performance levels in the provision of patient care and treatment. Findings included: Review of iQIES (an internet-based system used by CMS to manage provider and patient information), on 12/09/2025 revealed the Agency’s OASIS error summary report for the report period of 12/09/2024 to 12/09/2025. Review of the report revealed the following: error description “Record Submitted Late: The submission date was more than 30 days after the M0090 date on this new record… [The number] of assessments processed 102… [The number] of assessments with error 80 [and the percentage] of assessment with error [78.43 %].” Continued review of iQIES revealed the agency’s “OASIS Agency Final Validation” reports from 12/09/2024 to 12/09/2025. Review of the agency’s “OASIS Agency Final Validation” reports revealed the following: that the agency submitted (80 of 102) OASIS assessments late (more than 30 days after the M0090 date). During an interview with the Admin and Alt Admin on 12/12/2025 at 2:14 p.m., the surveyor asked who at the agency was responsible for encoding and transmitting the agency’s OASIS assessments. The Admin stated that the agency’s individual nurses (or PT) were responsible for encoding and completing the OASIS assessments. The Admin stated that (the Admin) and Alt Admin were responsible for submitting, transmitting, or exporting the OASIS assessments. The surveyor reviewed the findings and asked what the agency processes were. The Admin stated that when the OASIS is ready (completed) the agency exported it. The surveyor asked why the OASIS reports were transmitted late (80 of 102 OASIS submitted late, 78.43 %). The Admin stated that the notes (OASIS) were not completed timely; and if the OASIS were not there (completed timely by the agency nurses), then it delayed the exporting of the OASIS. The surveyor asked what the agency could have done differently to ensure that agency process, policy and regulations were followed. The Admin stated that it goes back to prioritizing the task of getting the OASIS completed timely (by agency nurses). Review of agency policy titled, “Timelines IM.35” dated 07/01/25 read in part: “…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 30 days of the M0090 date…” Review of the Centers for Medicare and Medicaid Services (CMS) website OASIS User Manuals | CMS on 12/17/2025 revealed that, “…The Outcome and Assessment Information Set (OASIS) is a group of standard data elements home health agencies (HHAs) integrate into their comprehensive assessment, to collect and report quality data to the Centers for Medicare & Medicaid Services (CMS)…The M0090 date 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 responses was completed…” Review of Texas Health and Human Services Website at, OASIS Resources | Texas Health and Human Services, on 12/17/2025 revealed the following, “Certified Home health agencies (HHAs) or those seeking initial certification under the Medicare conditions of participation are required to collect and encode (data enter) the Outcome and Assessment Information Set (OASIS) items, which are part of the comprehensive assessment of patients. In addition, agencies must transmit OASIS information on Medicare and Medicaid patients within 30 days of completing the assessment…””

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on record review and interview the agency failed to ensure that all entries were complete, and appropriately authenticated (by signature and title or secured unique identifier), dated, and timed by the primary author who had reviewed and approved the entry for one (Patient # 9) of two patient records reviewed in which the agency DON was the primary author of the plan of care, in that: the agency failed to ensure that the DON signed, titled, dated, and timed Patient # 9’s admission plan of care (by start of care on 12/09/2024). The failure placed the client at increased risk of harm if nursing care and services were not current, accurate, ordered, and monitored by the nurse, who was the primary author of the plan of care. Findings include: Patient # 9 Review of the clinical record for Patient # 9 revealed a POC for the certification period of 12/09/2025 to 02/06/2026. Review of the POC revealed a start of care date of 12/09/2024 and a primary diagnosis of Diabetes mellitus with diabetic chronic kidney disease (a disease where chronic elevated levels of sugar in the blood caused damage to the kidneys). Review of the POC did not reveal that an agency RN had signed and dated the POC on or before 12/09/2024. The POC contained an order for SN visits one time a week for nine weeks and an order for physical therapy to evaluate and treat. Further review of the record revealed a record titled, “Episode Summary.” Review of the episode summary revealed that the plan of care had been assigned to the DON on 12/09/2024. Continued review of the episode summary revealed that the POC was “In Progress.” During an interview with the Admin/PT and Alt Admin on 12/12/2025 at 2:11 p.m., the surveyor asked who was responsible for ensuring the patient’s plan of care was authenticated (signed, titled, dated, and timed). The Admin/PT stated that it was the responsibility of the person who completed the POC and the Admin/PT. The surveyor reviewed the findings and asked to speak with the DON. The Alt Admin called the DON. During a telephone interview with the DON on 12/12/2025 at approximately 2:11 p.m. the surveyor asked what the agency’s processes were for signing the patient’s plan of care. The DON replied, “I should have signed it. I believe, the timeframe is within the week that it is created.” The surveyor asked why the POC was not authenticated in accordance with agency policy and regulation. The DON replied, “It must have been one that I missed.” The surveyor asked what the DON could have done differently to ensure that the POC was authenticated. The DON replied, “I could have gone back and double checked.” Review of agency policy titled, “Authorization and Authentication of Medical Record Entries” last reviewed 05/01/2025 read in part: “Purpose [:] I. To identify the authors of medical record entries… Policy [:] All medical record entries whether paper, electronic, or combination format will be legible, clear, complete, made by appropriate staff, and authenticated as true and accurate by the author of the entry… Procedure [:] IV. Each medical record entry will be dated, timed, and signed with the complete name and title of the person making the entry…””

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on record review, observation and interviews, the agency failed to ensure the patients’ right to be advised of the name, address, and telephone number of a federally funded entity that serviced the area where the patient resided, in four (Patients # 1, 2, 3 and 4) of four patients who received home visits. The agency failed to advise the patients of the Quality Improvement Organization (QIO’s) name, address, and telephone number that serviced the area where the patients resided. The failure placed the patients’ health and safety at risk if they were unable to access the QIO to appeal a premature discharge. The failure could place the patients at risk of not having time to access needed resources (medical equipment or outpatient services) that were available for them in their service area. Findings included: Review of agency’s record titled, “Contact Information…Federal and State Public Agencies” dated 01/13/18 revealed the name, address, and telephone number of a (Former QIO) Quality Improvement Organization (federally funded entity). Further review of the record revealed that the name, address, and telephone number of the Quality Improvement Organization was not correct. Review of agency’s record titled “Notice of Medicare Non-Coverage” dated 12/31/2011 revealed that the notice had an area to insert the name and number of the Quality Improvement Organization. The area was completed but the name and the contact number listed was not correct. Patient # 1 Review of the clinical record for Patient # 1 revealed a POC for the certification period of 12/05/2025 to 02/02/2026. Review of the POC revealed a start of care date of 12/05/2025 and a primary diagnosis of Hemiplegia following a cerebral infarction affecting left side (left side paralysis following a stroke). The Admin/PT signed and dated the POC on 12/05/2025. The POC contained an order for PT visits two times per week for one week; three times per week for three weeks; and two times per week for one week. During a home visit, record review, observation, and interview on 12/10/2025 at approximately 11:45 a.m., the surveyor observed Admin/PT provide physical therapy services for Patient # 1. The surveyor reviewed the agency folder, which included patient rights records, which was provided to the patient at admission. Review of the records revealed that it included the following: the agency’s record titled, “Contact Information…Federal and State Public Agencies” dated 01/13/18 with the name, address, and telephone number of a (Former QIO) Quality Improvement Organization (federally funded entity). Further review of the record revealed that the name, address, and telephone number of the Quality Improvement Organization was not correct; and the agency’s record titled “Notice of Medicare Non-Coverage” dated 12/31/2011 that had an area to insert the name and number of the Quality Improvement Organization. The area was completed but the name and the contact number listed was not correct. The surveyor asked Patient # 1 if the agency staff had provided name and contact information for how to appeal a discharge if Patient # 1 did not agree with the discharge decision. Patient # 1 replied, “No.” Patient # 3 Review of the clinical record for Patient # 3 revealed a POC for the certification period of 11/10/2025 to 01/08/2026. Review of the POC revealed a start of care date of 09/11/2025 and a primary diagnosis of Wedge compression fracture of thoracic vertebra (happens when a vertebra or bone of the spine in the midback collapse and forms a wedge shape, caused by fragile bones or injury). The Admin/PT signed and dated the POC on 11/06/2025. The POC contained an order for PT visits two times per week for four weeks and one time per week for four weeks. During a home visit, record review, and interview on 12/10/2025 at 1:30 p.m., the surveyor reviewed the agency folder, which included patient rights records, which was provided to the patient at admission. Review of the records revealed that it included the following: the agency’s record titled, “Contact Information…Federal and State Public Agencies” dated 01/13/18 with the name, address, and telephone number of a (Former QIO) Quality Improvement Organization (federally funded entity). Further review of the record revealed that the name, address, and telephone number of the Quality Improvement Organization was not correct; and the agency’s record titled “Notice of Medicare Non-Coverage” dated 12/31/2011 that had an area to insert the name and number of the Quality Improvement Organization. The area was completed but the name and the contact number listed was not correct. The surveyor asked Patient # 3 if the agency staff had provided name and contact information for how to appeal a discharge if Patient # 3 did not agree with the discharge decision. Patient # 3 looked at a family member in the room and did not answer. Patient # 4 Review of the clinical record for Patient # 4 revealed a POC for the certification period of 11/02/2025 to 12/31/2025. Review of the POC revealed a start of care date of 11/13/2023 and a primary diagnosis of Parkinson’s disease (a neurological or nerve disorder that worsens over time and causes tremors, stiffness, slow movement, and balance problems). The Admin/PT signed and dated the POC on 10/30/2025. The POC contained an order for PT visits one time per week for eight weeks. During a home visit, record review, and interview on 12/10/2025 at 1:30 p.m., the surveyor reviewed the agency folder, which included patient rights records, which was provided to the patient at admission. Review of the records revealed that it included the following: the agency’s record titled, “Contact Information…Federal and State Public Agencies” dated 01/13/18 with the name, address, and telephone number of a (Former QIO) Quality Improvement Organization (federally funded entity). Further review of the record revealed that the name, address, and telephone number of the Quality Improvement Organization was not correct; and the agency’s record titled “Notice of Medicare Non-Coverage” dated 12/31/2011 that had an area to insert the name and number of the Quality Improvement Organization. The area was completed but the name and the contact number listed was not correct. The surveyor asked Patient # 4 if the agency staff had provided name and contact information for how to appeal a discharge if Patient # 4 did not agree with the discharge decision. Patient # 4 replied, “No.” Patient # 2 Review of the clinical record for Patient # 2 revealed a POC for the certification period of 11/20/2025 to 01/18/2026. Review of the POC revealed a start of care date of 09/21/2025 and a primary diagnosis of Urinary tract infection (an infection in urinary system, tube to the bladder, bladder, tubes to the kidneys, or kidneys). The DON signed and dated the POC on 11/19/2025. The POC contained an order for SN visits one time a week for nine weeks. During a home visit, record review, observation, and interview on 12/11/2025 at approximately 2:00 p.m., the surveyor observed RN A assess Patient # 2’s blood pressure, heartbeat, breathing, skin intactness, and assistance with transfer from chair to wheelchair. The surveyor reviewed the agency folder, which included patient rights records, which was provided to the patient at admission. Review of the records revealed that it included the following: the agency’s record titled, “Contact Information…Federal and State Public Agencies” dated 01/13/18 with the name, address, and telephone number of a (Former QIO) Quality Improvement Organization (federally funded entity). Further review of the record revealed that the name, address, and telephone number of the Quality Improvement Organization was not correct; and the agency’s record titled “Notice of Medicare Non-Coverage” dated 12/31/2011 that had an area to insert the name and number of the Quality Improvement Organization. The area was completed but the name and the contact number listed was not correct. Patient # 2 requested that the surveyor contact (Patient # 2’s) representative (Family member # 1) for interview questions. During an interview with on 12/12/2025 at 11:03 a.m. with Patient # 2’s representative (Family member # 1) the surveyor asked if the agency staff had provided the name and contact information for how to appeal a discharge if Patient # 2 or Family member # 1 did not agree with the discharge decision. Family member # 1 stated that the agency explained the discharge option. During an interview on 12/12/2025 at 2:46 p.m. with the Admin/PT and Alt Admin the surveyor asked who was responsible for ensuring that the agency’s patient rights information for federally funded entities (Quality Improvement Organization name and contact information) was correct. The Admin/PT stated that (Admin/PT and Alt Admin were responsible. The surveyor asked what the agency’s processes were to ensure the information was correct. The Admin/ PT stated that all of patient right records were in the packet in the patient’s home. Admin/PT stated that it was the admitting clinician’s responsibility to make the patient aware of and go over the information with each patient. The Admin/PT stated that (Admin/PT) went over a check list with the patients and had them sign an acknowledgement that they received the records and inform them to let the agency know if they had questions. The surveyor reviewed the findings and asked Admin/PT if (Admin/PT) was aware that the agency’s record for federally funded entities did not include the correct name, address, and telephone number of the (Current QIO) Quality Improvement Organization that served the area where the patients resided. The Admin/PT stated that he was not aware that the information was not correct. Admin/PT replied, “If it was still in the policy then we would not have known, but it is still our responsibility.” The surveyor asked what the agency could have done differently to ensure that the agency’s processes, policies, and regulations are followed. Admin/PT stated that the agency could make sure that the information was correct, provide correct information to the agency’s patients, and make sure to check with agency policies. Review of agency policy titled “Patient/Client Rights and Responsibilities” last reviewed 05/01/24 read in part: “Purpose [:] To ensure all patients/clients, representatives (if any), and agency staff acknowledge, observe, and implement the patient’s/client’s rights and responsibilities…Procedure [:] I. Agency staff will be responsible for knowing, observing, and implementing the patient’s/client’s rights, patient/client conduct, and patient/client responsibilities on a continuous basis…VI. The patient/client has the right to…K. Be advised of the names, addresses, and telephone numbers of the following Federally funded and state-funded entities that service the area where the patient/client resides: 1. Agency on Aging 2. Center for Independent Living 3. Protection and Advocacy Agency, 4. Aging and Disability Resource Center; and 5. Quality Improvement Organization...” Review of Center for Medicare Advocacy website on 12/09/2025 at, https://medicareadvocacy.org/medicare-quality-improvement-organization-changes-name/, revealed the following: Beneficiary and Family-Centered Care Quality Improvement Organizations (BFCC-QIOs) help Medicare beneficiaries with their concerns about quality of care, and in filing an appeal if coverage is ending too soon. As of July 1, 2024, the BFCC-QIO formerly known as [Former QIO] is officially [Current QIO]. In December of 2022, CNSI, “a leading provider of innovative healthcare technology solutions,” and [Former QIO], “a leading provider of technology-enabled care management, quality oversight and clinical assessment services” merged. The [Current QIO] brand was born in 2023, and notices with the new brand’s logo have been received by Medicare beneficiaries. [Current QIO] assures beneficiaries there have been no changes to the services it provides. [Current QIO]’s service areas include the following CMS Regions…Region 6…[Texas]…””