Kinesis Home Health Care LLC

“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 assessment to the CMS system within 30 days of completing patient assessments for 38 of 215 assessments processed during the review period of 4/30/2025-4/30/2026. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare and improve patient care failing to be reported to CMS in the required time frame. Findings included: In review of the HHA Error Summary Report for the period 4/30/2025-4/30/2026, the report identified Error #-3330. The description for Error #-3300 read in part, “Record Submitted Late: The submission date was more than 30 days after M0090 (item M0090 specifies the date the actual assessment was completed) on this new record.” Documentation further identified that 38 assessments contained this error, accounting for 17.67% of assessments completed by the Agency during the review period. In an interview with Administrator and Alternate Supervising Nurse (via phone) on 5/21/2026 at 1:30 PM Surveyor 1 reviewed OASIS HHA Error Summary Report with the above information. Surveyor 1 asked who was responsible for ensuring timely uploads of required information, and the Alternate Supervising Nurse stated the responsibility was hers at this time. The Administrator acknowledged the late submissions and stated they were due to office staff who were not meeting expectations for timely uploads and no longer employed at the agency. The Administrator acknowledged it was ultimately his responsibility to ensure OASIS submission was done timely and he was monitoring for timely completion going forward. When asked why timely submission was important for patient care, the Alternate Supervising Nurse stated to ensure submission of patient information was timely so [HHSC] had the information. Review of agency’s Administrative Policy Manual last reviewed: 010126, under section IM.35 “Timelines” reads 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.””

“Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This Standard is not met as evidenced by: Based on record review and interview, the agency failed to enforce their own written policy stating that bloodborne pathogen (a germ that can be carried in blood that can spread disease if it enters another person’s body) education and documentation will be completed as outlined in the Bloodborne Pathogen Program, per Occupational Safety and Health Administration (OSHA) for direct care staff upon hire and annually thereafter in 4 (Alternate Administrator/DON, Alternate Supervising Nurse, MSW A and RN A) out of 4 personnel records reviewed. Failure of the agency to ensure direct care staff received annual training on bloodborne pathogens placed the employees at risk for not having the latest information regarding bloodborne pathogens, which could impact their ability to provide care that protected both staff and patients from exposure to bloodborne diseases. Findings included: Review of agency’s Administrative Policy Manual, last reviewed: 050125, Section IC.5 “Exposure Control Plan”, under “Policy” read in part “I. The Agency is committed to providing a safe and healthy work environment for the entire staff. In accordance with federal and state laws and regulations, the Agency will design, implement, and evaluate annually an Exposure Control Plan which will include: …C. Ensuring that education, exposure follow-up, and documentation will be completed as outlined in the Bloodborne Pathogen Program, per Occupational Safety and Health Administration (OSHA), 29 CFR (code of federal regulations) Part 1910.1030, relating to Bloodborne Pathogens, Airborne Pathogens Program, and Hazardous Materials program.” Further review revealed under “Procedure” which read in part “II. Methods of Implementation of an Exposure Control Plan A. On hire and annually, all HCP (healthcare personnel) will be provided education on the exposure control plan.” Review of the OSHA 29 CFR Part 1910.1030, titled “Bloodborne Pathogens”, and last updated 5/14/2019 (https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1030), revealed regulations that read, in part, “Information and Training: The employer shall train each employee with occupational exposure in accordance with the requirements of this section. Such training must be provided at no cost to the employee and during working hours. The employers shall institute a training program and ensure employee participation in the program. Training shall be provided as follows: At the time of initial assignment to tasks where occupational exposure may take place; At least annually thereafter. Annual training for all employees shall be provided within one year of their previous training.” Review of the personnel records for Alternate Administrator/DON revealed a hire date of 9/26/2024 and signed agency policy statement date of 12/17/25. Further review revealed Alternate Administrator/DON’s file contained record of completing bloodborne pathogen training as part of orientation on 9/26/2024, but no other documentation of annual training thereafter could be located in the file or anywhere else within the agency. Review of the personnel records for Alternate Supervising Nurse revealed a hire date of 8/16/2021 and signed agency policy statement date of 2/9/2022. Further review revealed Alternate Supervising Nurse’s file contained record of completing bloodborne pathogen training as part of orientation on 9/26/2021, but no other documentation of annual training thereafter could be located in the file or anywhere else within the agency. Review of the personnel records for MSW A revealed a hire date of 6/18/2020 and signed agency policy statement date of 6/18/2020. Further review revealed MSW A’s file contained record of completing bloodborne pathogen training as part of orientation on 6/18/2020, but no other documentation of annual training thereafter could be located in the file or anywhere else within the agency. Review of the personnel records for RN A revealed a hire date of 4/30/2019 and signed agency policy statement date of 4/30/2019. Further review revealed RN A’s file contained record of completing bloodborne pathogen training as part of orientation on 4/30/2019, but no other documentation of annual training thereafter could be located in the file or anywhere else within the agency. In an interview initially with the Administrator on 5/21/2026 at 4:04 PM Surveyor 1 asked Administrator who was responsible for ensuring direct care staff received the required annual bloodborne pathogen training and he stated [Alternate Supervising Nurse]. Surveyor 1 requested [Alternate Supervising Nurse] be contacted, and the interview continued with Administrator and Alternate Supervising Nurse (via phone). Surveyor 1 asked if bloodborne pathogen training had been completed annually for each direct care staff member, and the Alternate Supervising Nurse stated the training was completed upon hire and annually thereafter. When asked for verification of annual training, the Alternate Supervising Nurse stated the agency utilized Company A (an online company that provided federal, state, and accrediting organization-specific policies and forms) and stated Company A does not have training that used quizzes or provided certificates of completion but instead the staff reviewed the agency policy as the annual training. When asked which policy was being reviewed, the Alternate Supervising Nurse stated she could not recall without being able to look at it. The Administrator also stated he was unable to confirm which policy was being reviewed. Surveyor 2 verbally read the OSHA requirement that states “The employer shall train each employee with occupational exposure in accordance with the requirements of this section. Such training must be provided at no cost to the employee and during working hours. The employers shall institute a training program and ensure employee participation in the program. Training shall be provided as follows: At the time of initial assignment to tasks where occupational exposure may take place; At least annually thereafter. Annual training for all employees shall be provided within one year of their previous training”. The Administrator and Alternate Supervising Nurse stated they were unable to provide documentation which verified completion of annual bloodborne pathogen training in accordance with OSHA requirements and were unable to provide records from Company A that demonstrated when direct care staff received the training. Surveyor 1 asked why it was important to ensure all required training be completed regarding bloodborne pathogens and Alternate Supervising Nurse stated so [direct care staff] are not passing on contagions (illnesses or germs that can spread from one person to another) to patients.”