Patient Centered Services Inc.

“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 the assessment of the patient for 6 of 104 assessments processed for the time reviewed from 1/1/2025 to 12/31/2025. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare failing to be reported to CMS in the required time frame. The findings included: The HHA Error Summary Report, retrieved from the iQIES website for the time of 1/1/2025 to 12/31/2025 was reviewed. Review of the HHA Error Summary Report for the time-period 1/1/2025 to 12/31/2025 identified Error #-3330. The description for Error #-3330 read in part, “Record Submitted Late: The submission date is more than 30 days after M0090 (Item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with the error was 6 assessments and the percentage of assessments with this error was 5.77% of the total of 104 assessments completed by the Agency. An interview was conducted with the Administrator on 2/17/2025 at 12:00 p.m. The HHA Error Summary Report was reviewed with the Administrator. The Administrator stated the Agency both acknowledged the responsibility of the late submission. The Administrator also stated that the issue was likely just an oversight and quality assurance issues. During a record review of an Agency policy titled, “Timelines,” dated for revision 1/29/2020, read in part, “…All completed and encoded OASIS data will be transmitted within 30 days of the [admission] date…””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, record review and interview, the agency failed enforce written policies addressing infection control including the prevention of the spread of infectious and communicable disease with 1 of 8 of the agency’s patients reviewed (Patient #1), in that: 1)LVN A failed to perform hand hygiene (use of soap and water/ hand sanitizer to clean hands) during home visit with Patient #1. 2) LVN A failed to clean reusable medical equipment (thermometer, blood pressure monitor, and pulse oximeter (used to measure heart rate and blood oxygen percentage) during home visit with Patient #1. This failure placed the agency’s patients at risk for an infection. Findings include: During a home observation for Patient #1, on 2/18/2026 at 10:30 a.m., LVN A was observed providing patient care. Further observation of LVN A revealed LVN A donned (wore) gloves prior to touching of Patient #1, touching reusable equipment, and touching Patient #1’s medications with no hand hygiene observed. Further observation revealed that LVN A returned reusable medical equipment to supply bag without cleaning the equipment. During record review of Patient #1’s plan of care revealed a start of care date of 5/18/2022 and a certification period of 12/28/2025-2/25/2026. Further record review reveal that Patient #1 was receiving skilled nursing services once weekly. During an interview with LVN A on 2/18/2026 at 11:00 AM, LVN A was informed of the findings. LVN A stated he was instructed on infection prevention by the agency but forgot supplies in the car. LVN A stated that the agency’s infection control class was taken. During an interview with the Administrator on 2/19/2026 at 12:30 p.m., the Administrator was informed of the above findings. The Administrator stated that the agency staff was instructed on infection control annually, but and understood that the deficient practice can lead to a high risk of infection for the agency patients. During a record review of agency policy titled “Hand Hygiene”, revision date 1/29/2020, read is part, …”all agency staff providing patient/ client care will observe proper hand hygiene technique: prior to initial entry into supply bag, before providing direct patient/client care, following each patient/client contact even when gloves are worn…”. Record review of the agency policy titled, “Bag Technique, revision date 1/29/2020, read in part, “…When the visit is completed, reusable equipment is cleaned using alcohol, and soap and water as appropriate...for your reusable tourniquet, use and water and/or alcohol…””