Sunshine Therapy & Nursing 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 (Outcome and Assessment Information Set) assessments to the CMS system within 30 days of completion in 5 of 12 months of transmissions reviewed (February 2024, May 2024, August 2024, September 2024, and November 2024). This failure prevented the patient’s data from being made available to Center for Medicare and Medicaid (CMS) for analysis to identify agency performance levels in the provision of patient care. The findings included: Record review of IQIES (electronic system used to transmit quality measures from the OASIS data collected during comprehensive assessments) “Home Health Error Summary by Agency” report generated from the CMS national data system during presurvey preparation on 02/12/25 revealed Agency had submitted and processed 138 assessments. The report also revealed the Agency had 9 assessments with error -3330 indicating those records were submitted after the 30th date of the M0090 (assessment) date, which equals to 6.52% of the total assessments submitted in error. Record review of the OASIS Agency Final Validation report with the following submission date 02/06/24 and a report period of 02/01/24 through 02/29/24 revealed 1 total record were submitted. Further review of this report revealed 1 of 1 (record 1) record processed with error -3330 indicating those records were submitted after the 30th date of the M0090 date. Record review of the OASIS Agency Final Validation report with the following submission date 05/06/24 at 11:35 and a report period of 05/01/24 through 05/31/24 revealed 1 total record were submitted. Further review of this report revealed 1 of 1 (record 1) records processed with error -3330 indicating those records were submitted after the 30th date of the M0090 date. Record review of the OASIS Agency Final Validation report with the following submission date 05/06/24 at 11:35:09 and a report period of 05/01/24 through 05/31/24 revealed 1 total record were submitted. Further review of this report revealed 1 of 1 (record 1) record processed with error -3330 indicating those records were submitted after the 30th date of the M0090 date. Record review of the OASIS Agency Final Validation report with the following submission date 08/15/24 and a report period of 08/01/24 through 08/31/24 revealed 1 total record were submitted. Further review of this report revealed 1 of the 1 (record 1) record processed with error -3330 indicating those records were submitted after the 30th date of the M0090 date. Record review of the OASIS Agency Final Validation report with the following submission date 09/23/24 and a report period of 09/01/24 through 09/30/24 revealed 1 total record were submitted. Further review of this report revealed 1 of 1 (record 1) records processed with error -3330 indicating those records were submitted after the 30th date of the M0090. Record review of the OASIS Agency Final Validation report with the following submission date 11/01/24 and a report period of 11/01/24 through 11/31/24 revealed 1 total record were submitted. Further review of this report revealed 2 of 2 (record 1 and 2) record processed with error -3330 indicating those records were submitted after the 30th date of the M0090. Record review of the OASIS Agency Final Validation report with the following submission date 11/13/24 and a report period of 11/01/24 through 11/31/24 revealed 1 total record were submitted. Further review of this report revealed 1 of 1 (record 1) record processed with error -3330 indicating those records were submitted after the 30th date of the M0090. Record review of the OASIS Agency Final Validation report with the following submission date 11/15/24 and a report period of 11/01/24 through 11/31/24 revealed 1 total record were submitted. Further review of this report revealed 1 of 1 (record 1) record processed with error -3330 indicating those records were submitted after the 30th date of the M0090. In an interview with Adm, DON, and office manager on 02/20/25 4:00 p.m., Office manager stated she was responsible for submitting OASIS information to CMS. Office manager and Adm did not dispute the errors and confirmed they did have several late submissions. Adm confirmed it is agency policy to transmit and encode oasis within 30 days of completing the assessment. Surveyor asked why they had late submissions for their Oasis. Office manager stated, “Some may be duplicate submissions. Sometimes the system is slow, and I’ll submit them, but it won’t go in until the next day. That may cause them to be late.” DON stated, “We may have some late submissions due to RN’s turning in them late.” Adm and office manager further confirmed it will not affect client care. Review of agency Policy and Procedure Manual “Timelines” with a revision date of 10/25/24, quoted in part: “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… It will be transmitted using electronic communications software that complies with the Federal Information Processing Standard from the Agency or the Agency contractor to the CMS collection site within 30 days of the M0090 date.” The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provided additional information, no other information provided.”