Assured 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 transmit discharged patient data to the Centers for Medicare and Medicaid Services (CMS) database in a timely manner for 464 of 3046 records transmitted between 05/01/23 and 05/31/24. Failure to transmit patient data timely could result in inaccurate data and cause delays for patients to receive full benefits. 1. As part of the pre-survey preparation, Surveyor #5 reviewed the “HHA Error Summary by Agency” report from 05/01/23 and 05/31/24 generated from the iqies.cms.gov site. The review showed that the agency had 464 of 3046 patient assessments that were not submitted in a timely manner. This resulted in a 15.23% late submission error rate. 2. On 06/25/24 at 12:00 PM, Surveyor #5 interviewed the Executive Director (Staff #501) regarding the error rate. Staff #501 stated that they had no awareness of any late submissions but that the reports are reviewed by the cooperate office. Staff #501 stated that they notified the cooperate office about the error percentage and that they will review the information to determine why the report is showing late submissions.”

“Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA’s quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This Standard is not met as evidenced by: Based on interview and record review, the agency failed to operationalize infection control policies and procedures consistent with state regulations that included conducting tuberculosis (TB) risk assessments at hire for 2 of 2 contractors that provided direct patient care (#508 and #509). Failure to perform TB risk assessments of staff may result in the risk of patients’ exposure to tuberculosis (TB). Reference: WAC 246-335-525 PERSONNEL, CONTRACTOR, AND VOLUNTEER POLICIES - The applicant or licensee must develop and operationalize personnel, contractor, and volunteer policies and procedures that describe: (15)(c)(i) Infection control practices, communicable disease testing, and vaccinations. Policies and procedures must include, at minimum: Conducting a TB risk assessment for all new employees upon hire. Agencies must use a tuberculosis risk assessment form provided by the department. Based on risk assessment results, determine the agency’s responsibility to conduct TB testing of new employees. If TB testing is required, follow the department’s tuberculosis risk assessment form testing recommendations; Findings included: 1. Document review of the agency’s policy titled, “Patient Care Contracted Workers Requirement,” (last revised 06/01/24) showed that during the pre-screening process the agency would obtain health screenings as required by state law and maintain the documents in a medical file. 2. Surveyor #5 reviewed the employee file for a contracted Registered Nurse (RN) (Staff #508). The record showed that Staff #508 was hired on 06/10/24. The record showed no evidence that a Department of Health TB risk assessment was conducted on hire by the agency. Surveyor #5 reviewed the employee file for a contracted Registered Nurse (RN) (Staff #509). The record showed that Staff #509 was hired on 06/03/24. The record showed no evidence that a Department of Health TB risk assessment was conducted on hire by the agency. 3.On 06/25/24 at 1:00 PM, Surveyor #5 interviewed the agency’s Business Office Manager (Staff #502) regarding the state requirement to perform a TB risk assessment on hire for contacted staff. Staff #502 stated that they were unaware that the agency was required to complete the TB risk assessments on contracted employees.”