Peculiar Care Home Health 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 20 of 81 (24.69%) assessments processed for the time reviewed of 1/1/2024 to 12/31/2024, 18 of 63 (28.57%) assessments processed for the time review of 1/1/2025 to 12/31/2025, and 7 of 41 (17.07%) assessments processed for the time period of 1/1/2026- 9/8/2026. This failure resulted in quality data not being used to continuously improve patient care by failing to be reported to CMS in the required time frame Findings include: Record review of the HHA Error Summary Report, retrieved from the IQIES, an internet-based system developed by the Centers of Medicare and Medicaid services to manage and evaluate healthcare quality across providers, website for the time of 1/1/2024 to 12/31/2024 was reviewed. Review of the HHA Error Summary Report in IQIES for the time-period 1/1/2024 to 12/31/2024 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 that the number of assessments with errors was 20 assessments and the percentage of assessments with this error was 24.69% of the total of 81 assessments completed by the Agency. Record review of 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 in IQIES for the time-period 1/1/2025 to 12/31/2025 identified Error #-3330. The documentation identified that the number of assessments with the error was 18 assessments and the percentage of assessments with this error was 28.57% of the total of 63 assessments completed by the Agency. Record review of the HHA Error Summary Report, retrieved from the IQIES website for the time of 1/1/2026 to 9/8/2026 was reviewed. Review of the HHA Error Summary Report in IQIES for the time-period 1/1/2026 to 9/8/2026 identified Error #-3330. The documentation identified that the number of assessments with errors was 7 assessments and the percentage of assessments with this error was 17.07% of the total of 41 assessments completed by the Agency. An interview was conducted with the DON on 9/11/2026 at 11:15 AM. The HHA Error Summary Report was reviewed with DON. The DON stated that it was her responsibility to submit OASIS data. When asked why the submissions were late, DON stated that sometimes they receive an insurance referral from a different company and if she doesn’t “select all” during the process, these assessments get missed. DON stated with their low census it’s difficult because even 1 late submission has a large impact on their compliance percentage. Surveyor asked DON if she knew what their policy said regarding the timeline for submission. DON stated that policy says she has 30 days which is “plenty of time” to get it done. An exit interview was held with Admin, Alt Admin, and DON on 9/11/2026 at 12:30 PM. OASIS submission percentages was reviewed. Alt admin acknowledged the late submissions. During a record review of an agency policy titled, “Medical Record Information Timelines” dated 05/01/2011 read in part, “… completed and encoded OASIS data will be transmitted to the state 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 written policies addressing bloodborne pathogens, harmful germs carried in human blood and certain bodily fluids that can make you sick, training annually in 3 (ATT A, ATT B, ATT C) of 7 employee records reviewed. This failure placed staff and patients at risk of harm from bloodborne illnesses and transmitting disease. Findings include: Record review on 9/11/2026 of the OSHA regulation on the website Osha.gov with a title “Occupational Safety and Health Administration”, revealed in part ,” Annual training for all employees shall be provided within one year of their previous training...The employer shall train each employee with occupational exposure in accordance with the requirement of this section...The employer shall institute a training program and ensure employee participation in the program...” Record review of ATT A employee file, date of hire 2/10/2022, revealed no bloodborne pathogens training for 3 (2023, 2024, 2025, and currently for 2026) of 3 years reviewed. There was no documentation of bloodborne pathogens training available for Surveyor review in agency binder titled “Inservice”. Record review of ATT B employee file, date of hire 7/1/2026, revealed no bloodborne pathogens training upon hire. There was no documentation of bloodborne pathogens training available for Surveyor review in agency binder titled “Inservice”. Record review of ATT C employee file, date of hire 10/8/2019, revealed no bloodborne pathogens training for 3 (2023, 2024, 2025, and currently for 2026) of 3 years reviewed. There was no documentation of bloodborne pathogens training available for Surveyor review in agency binder titled “Inservice”. An interview with Admin was conducted on 9/11/2026 at approximately 11:00 AM. Surveyor asked Admin who was responsible for annual OSHA education. Admin stated she was responsible. Surveyor asked if annual bloodborne pathogens training was provided to the attendants. Admin stated that since the agency transitioned to direct deposit to pay the attendants, it’s been very difficult to get them to come in for annual training. Surveyor asked Admin when they transitioned to direct deposit and Admin stated that she wasn’t sure. Surveyor asked if there was any bloodborne pathogens training for ATT A and ATT C for years 2023, 2024, 2025, or currently for 2026 and any bloodborne pathogens training for ATT B upon hire. Admin searched her training folders and was unable to locate documents confirming training. Admin stated that it wasn’t done because they couldn’t get the attendants to come into the office. An exit conference was conducted on 9/11/2026 at 12:30 PM with Admin, Alt Admin, and DON. Surveyor asked if they knew their policy regarding bloodborne pathogens training and who was required to receive it. Alt Admin stated that everyone needed it. Review of agency policy titled “Agency Inservice’s and Education” dated 09/01/2012 read in part, “…Direct [patient] care staff are required to attend the following in-services annually… bloodborne/ airborne pathogen program…”.”

“Participate in the HHA’s QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA’s QAPI program; and This Element is not met as evidenced by: Based on record review and interview, the agency failed to establish a QAPI Committee that included the minimum required membership for 3 of 3 QAPI meetings conducted in that: The agency failed to ensure all (PT, OT, ST, MSW, PHC, Nursing) skilled professional services were represented and included a participating member to contribute to all phases of the QAPI program. This failure placed agency patients at risk by limiting the agency’s ability to effectively evaluate, monitor, and improve the quality and safety of all services provided. Findings include: Record review of the agency’s QAPI program revealed a QAPI meeting was conducted with a completion date of 2/16/2024. The meeting minutes revealed that the Admin, DON, RN, and 2 governing board members were present. There was no representation from PT, OT, ST, MSW, or PHC services. Record review of the agency’s QAPI program revealed a QAPI meeting was conducted with a completion date of 9/30/2024. The meeting minutes revealed Admin, DON, RN, and two Governing Board members were present. There was no representation from PT, OT, ST, MSW, PHC services. Record review of the agency’s QAPI program revealed a QAPI meeting was conducted with a completion date of 7/31/2025 The meeting minutes revealed Admin and two Governing Board members were present. There was no representation from nursing, PT, OT, ST, MSW, or PHC services. An interview was conducted with Admin and Alt Admin on 9/11/2026 at approximately 11:30 AM. Surveyor asked Alt Admin who was responsible for the QAPI. Alt Admin stated that he was responsible for QAPI. Surveyor asked who made up the QAPI committee and Alt Admin stated it was Admin and Alt Admin. An exit conference was conducted on 9/11/2026 at 12:30 PM. QAPI was addressed with Admin and Alt Admin. Surveyor asked if they knew their policy for QAPI meetings. Alt Admin stated that the policy says, “everyone must be present including therapy”. Surveyor asked Alt Admin why none of the QAPI meetings had representations from PT, OT, MSW, PHC services and why one meeting was missing nursing representation. Alt Admin stated, “the therapists want to be paid for coming in so it’s hard to get them to attend the meetings. We try to get them to attend but no one ever shows up because they want us to pay them for it”. Review of agency policy titled “Quality Assessment Performance Improvement Plan” dated 1/02/2007 read in part, “The QAPI committee will consist of, at a minimum, the Administrator, supervising nurse or therapist, and individuals representing the scope of services provided by the agency. The QAPI Committee will meet at least quarterly or more often, if needed”.”