Every finding on record at Absolute Healthcare Systems, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 09/06/24. Standard level deficiencies cited.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and Staff interview, it was determined the Agency failed to conduct a full-scale exercise, facility-based exercise, or activate the Agency’s Plan as required. Findings include: 1. The Emergency Preparedness Plan was reviewed on 09/04/24. The Plan contained documentation that the Agency conducted table-top exercises on 08/09/22, 06/01/23 and 06/14/24. During an interview with the Administrator and Director of Nursing on 09/05/24 at 10:00 AM, the Administrator stated that the Agency conducted and documented table-top exercises from 2022 to 2024. During the same interview, both confirmed that the Agency did not activate and document an actual Emergency Plan activation nor participate in a full-scale or facility-based exercise. 2. During an interview with the Administrator and Director of Nursing on 09/05/24 at 10:00 AM, both confirmed the above findings.

Recertification survey was conducted on 09/06/24. Standard level deficiencies cited. Abbreviations: # = number % = percent AM = morning SN = Skilled Nurse POC/PsOC = Plan of Care / Plans of Care BP = Blood pressure PM = afternoon/evening Pt./ Pts. = Patient/Patients OASIS = Outcome and Assessment Information Set lbs. = pounds

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 review of the Error Summary report and Staff interview, it was determined that in 170 of 504 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 06/2023 to 05/2024 (12 months), was reviewed on 09/05/24. The report included a warning for Error # -3330. The Error included 170 of 504 (33.73 %) assessments that were submitted late. During an interview with the Administrator and Director of Nursing on 09/05/24 at 10:00 AM, the Administrator stated that the timeframe for submission of OASIS is within 30 days after completion. 2. During an interview with the Administrator and Director of Nursing on 09/05/24 at 10:00 AM, the Administrator and Director of Nursing confirmed the above findings.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on the clinical record review and Staff interview, it was determined in 3 of 7 (Pts. # 2, 3, 4 and 5) clinical records reviewed, the patient care was not provided as ordered in the plan of care. Findings include: 1. Pts. #2 was admitted to the Home Health Services on 06/11/24 with the diagnosis of: Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Stage 1-4 Unspecified Chronic Kidney. The clinical record was reviewed on 09/03/24. The clinical record contained a POC dated 06/11/24, that required SN to assess the patient’s weight and pain, 1-2 times a week for 9 weeks. The clinical record lacked the SN visit and SN assessments for 06/25/24 (week #3). The clinical record included a SN visit assessment on 08/22/24, that lacked the patient’s weight. 2. Pts. #3 was admitted to the Home Health Services on 06/27/24 with the diagnosis of: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 07/02/24. The clinical record contained a POC dated 06/27/24, that required SN to assess the patient’s pain and weight, 1-2 times a week for 9 weeks. The clinical record included the SN visit note dated 08/28/24, that lacked the assessment of the patient’s pain and weight. 3. Pt. #4 was admitted to Home Health Services on 08/07/24 with the diagnosis of: Streptococcal Pharyngitis and Type 2 Diabetes Mellitus with Diabetic Nephropathy. The clinical record was reviewed on 09/04/24. The signed POC for certification period of 08/07/24 to 10/05/24, required to notify Physician of vital sign parameters…. “…. Blood sugar….” The SN note dated 08/14/24, lacked a diabetic assessment as ordered in the POC. 4. Pt. #5 was admitted to Home Health Services on 06/03/24 with the diagnoses of: Dysphagia, Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 09/04/24. The signed POC for certification period of 08/02/24 to 09/30/24, required to notify Physician of vital sign parameters…. “…. Systolic BP…. Diastolic BP….” The SN note dated 08/05/24, lacked a BP assessment as ordered in the POC. 5. During interviews with the Administrator and Director of Nursing on 09/04/24 between 2:00 PM to 3:00 PM, both confirmed the above findings.

Establishment of the Emergency Program (EP) CFR(s): 484.102 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness plan, staff in-service binder and staff interview, it was determined the Agency failed to review and update its Emergency Preparedness plan and policies biannually, ensure the plan was established based on a risk assessment, include volunteers and establish a policy for the use of volunteers, review and update its communication plan and policies biannually, conduct staff training and testing relative to the Agency's Emergency Plan. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency failed to review and update its Emergency plan and policies biannually (E-0004). 2. The Agency failed to ensure the Emergency plan was established based on a risk assessment (E-0006). 3. The Agency failed to ensure the Emergency plan include volunteers and a policy for the use of volunteers (E-0024). 4. The Agency failed to review and update its communication plan and policies biannually (E-0029). 5. The Agency failed to conduct staff training and testing relative to the Agency's Emergency Preparedness plan (E-0036). The cumulative effect of these systemic practices resulted in the Agency's inability to provide appropriate direction or supervision in the event of an emergency or disaster.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to review and update its Emergency Preparedness plan and policies biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness plan was reviewed on 7/26/21 at 12:30 PM. The Plan included documentation the Agency last reviewed and updated the plan on "02/08/2018". As of 7/26/21, the Agency failed to review and revise the plan every 2 years. 2. During an interview with the Administrator on 7/27/21 at 10:15 AM, the Administrator confirmed the above finding.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. *[For LTC facilities at §483.73(a)(1):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a)(1):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a)(2):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to ensure the Emergency plan was established based on a risk assessment. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness plan last updated on "02/08/2018" was reviewed on 7/26/21 at 12:30 PM. The plan contained a form titled, "Hazard Vulnerability Assessment" which was left blank. As of 7/26/21, the plan lacked documentation it was formulated based on an all-hazards approach risk assessment. 2. During an interview with the Administrator on 7/27/21 at 10:15 AM, the Administrator confirmed the Emergency Preparedness plan lacked a risk assessment.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to include volunteers, and establish a policy for the use of volunteers. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness plan last updated on "02/08/2018" was reviewed on 7/26/21 at 12:30 PM. The plan lacked documentation regarding the use of volunteers, and a policy relative to the duties and responsibilities of the volunteers. 2. During an interview with the Administrator on 7/27/21 at 10:15 AM, the Administrator confirmed the Emergency Preparedness plan lacked volunteers and a policy for the use of volunteers.

Development of Communication Plan CFR(s): 484.102(c) (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC). This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to review and update its communication plan and policies biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness plan last updated "02/08/2018" was reviewed on 7/26/21 at 12:30 PM. The plan contained: "Staff Directory, Patient Emergency Preparedness List, Call Tree, (staff) Assignment Sheet, Organizational Chart For Disaster Response Team". As of 7/26/21, the Agency consists of 2 employees (Administrator and Office Manager). The list identified above contained multiple names of staff that are no longer employed by the Agency. The "Patient Emergency Preparedness List" included 192 Pt. names. The Agency's current Pt. census is 1. The plan included: "If you are away from home when an emergency happens - Field staff/direct care staff 1. Call... for ... ". The plan included instructions to call staff that had separated from the Agency. As of 7/26/21, the Agency failed to review and revise the communication plan every 2 years. 2. During an interview with the Administrator on 7/27/21 at 10:15 AM, the Administrator stated all staff (excluding the Administrator and Office Manager) included the Emergency Preparedness plan "left the Agency in 2020 or early 2021." During the same interview, the Administrator confirmed the above findings.

EP Training and Testing CFR(s): 484.102(d) *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan, staff in-service binder and staff interview, it was determined the Agency failed to conduct staff training and testing relative to the Agency's Emergency Preparedness Plan. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Emergency Preparedness plan last updated on "02/08/2018" was reviewed on 7/26/21 at 12:30 PM. As of 7/26/21, the plan lacked documentation the Agency trained the staff on the Emergency Preparedness plan in 2018, 2019, 2020 and 2021 . 2. The Agency's staff in-service binder was reviewed on 7/27/21 at 10:15 AM. As of 7/27/21, the binder lacked documentation the Agency trained the staff on the Emergency Preparedness plan in 2018, 2019, 2020 and 2021. 3. The Emergency Preparedness plan last updated on "02/08/2018" included a post-it note/sticky note which contained: "May 14, 2018 Fire Drill Building". The note lacked the time and location of the drill, staff involved in the drill, person(s) that coordinated the drill, outcome or the after action plan from the drill. As of 7/27/21, the Agency was unable to provide any other documentation of testing its Emergency Preparedness plan. 4. During an interview with the Administrator on 7/27/21 at 10:15 AM, the Administrator confirmed the Agency failed to conduct staff training and testing relative to the Agency's Emergency Plan as required every 2 years, and maintain documentation of the training and testing.

. Recertification survey conducted. 42 CFR 484.80 (f)(3): Eligible Training & Competency Evaluation Organizations. Determination has been made that this Agency is not in compliance with the Conditions of Participation for: 42 CFR 484.55 Comprehensive Assessments of Patients. 42 CFR 484.60 Care Planning, Coordination, Quality of Care. 42 CFR 484.70 Infection Prevention and Control. 42 CFR 484.75 Skilled Professional Services. 42 CFR 484.102 Establishment of the Emergency Program. A Focused Infection Control survey (FIC) was conduced on 8/3/21. Determination has been made that this agency is not in compliance with the Conditions of Participation for: 42 CFR 484.70 Infection Prevention and Control. Therefore, the Agency is precluded from conducting Aide training and/or competency evaluations for 24 months effective 8/3/21. This applies even if the Agency is not currently conducting aide training and/or competency evaluation. Abbreviations: Pt./Pts.= Patient/Patients SN= Skilled Nurse RN= Registered Nurse POC/PsOC= Plan of Care/Plans of Care SOC= Start of Care OASIS= Outcome and Assessment Information Set Re-eval= Re- evaluate AM= Morning PM= Afternoon/Evening PT= Physical Therapy ST= Speech Therapy o2/O2= Oxygen nc/NC= Nasal cannula MG=Milligrams x= times /= per #= Number wk= week COVID-19 = Coronavirus disease 2019

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: . A. Based on review of clinical records and staff interview, it was determined that the Agency failed to ensure informed consents contained the disciplines that will furnish care and the frequency of visits. This was found in 3 of 6 (Pts. #3, 5 and 6) clinical records reviewed. Findings include: 1. The following clinical records were reviewed on 7/26/21 and 7/27/21 between 1:00 PM to 4:00 PM: Pt. #3 SOC: 05/07/19 Pt. #5 SOC: 01/27/21 Pt. #6 SOC: 03/12/21 The records lacked documentation of Pt. consenting to the disciplines that will furnish care and the frequency of visits. 2. During an interview with the Administrator on 7/28/21 from 2:30 PM to 3:30 PM, it was confirmed that the records lacked documentation of the patients' consents, to the frequency of visits/services to be provided prior to SOC.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: . A. Based on clinical record reviews, observation and interview during the home visit, Agency policy review and staff interview, it was determined the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date; failed to ensure the comprehensive assessment was accurate and/or complete. This has the potential to affect all Pts. receiving services. Findings Include: 1. In 5 of 6 clinical records reviewed, the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date (G514). 2. In 1 of 1 active clinical record reviewed, wherein home visit conducted, the Agency failed to ensure the comprehensive assessment was accurate and/or complete (G528). The cumulative effect of these systemic practices resulted in Agency's inability to provide care effectivily at the Start of Care.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, and staff interview, it was determined the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. This was found in 5 of 6 (Pts. #1, 2, 3, 5 and 6) clinical records reviewed. Findings include: 1. Pt. #1. SOC 6/15/21. Diagnoses: Bilateral Primary Osteoarthritis of Knee and Essential (Primary) Hypertension. The clinical record was reviewed on 7/26/21 at 1:20 PM. The record contained the SOC comprehensive assessment form completed by the SN and dated 6/15/21. The record/Agency lacked a referral to initiate service. The Face-to-Face form requiring "Skilled Nursing 1 x/week for 9 weeks" and signed by the Physician and dated 5/25/21. The record lacked documentation the Pt. was discharged or there was a Physician ordered SOC date. As of 7/26/21, the record lacked documentation the Agency initiated service within the required time frame. 2. Pt. #2. SOC 2/12/21. Diagnoses: Bilateral Primary Osteoarthritis of Hip and Unspecified Chronic Obstructive Pulmonary Disease. The closed clinical record was reviewed on 7/26/21 at 2:00 PM. The record contained the SOC comprehensive assessment form completed by the SN and dated 2/12/21. The record/Agency lacked a referral to initiate service. The Face-to-Face form required: "...SN services..." was signed by the Physician on 1/14/21 and faxed to the Agency on 1/25/21. The record lacked documentation the Pt. was discharged from an inpatient facility or there was a Physician ordered SOC date. As of 7/26/21, the record lacked documentation the Agency initiated service within the required time frame. 3. Pt. #3. SOC 4/9/20. Diagnoses: Stage 2 Pressure Ulcer of Sacral Region. The closed clinical record was reviewed on 7/26/21 at 3:00 PM. The record contained the SOC comprehensive assessment form completed by the SN and dated 4/9/20. The record/Agency lacked a referral to initiate service. The Face-to-Face form signed by the Physician on 2/3/20 required: "Skilled Nursing: 9 weeks, Re-eval in 9 weeks". The record lacked documentation the Pt. was discharged from an inpatient facility or there was a Physician ordered SOC date. As of 7/26/21, the record lacked documentation the Agency initiated service within the required time frame.. 4. Pt. #5. SOC 1/27/21. Diagnosis: Primary Generalized Osteoarthritis. The closed discharged clinical record was reviewed on 7/26/12 at 2:15 PM. The record included the SOC comprehensive assessment dated 1/27/21. The Face-toFace form signed by the Physician on 12/3/20 required: "PT to treat: weakness." The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 7/29/21, the Agency failed to start service within 48 hours of the referral date. 5. Pt. #6. SOC 3/12/21. Diagnosis: Bilateral Osteoarthritis of Knee. The closed/discharged clinical record was reviewed on 7/26/21 at 3:15 PM. The record included the SOC comprehensive assessment dated 3/12/21 which included, the referral date of 11/12/20. The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 7/29/21, the Agency failed to start service within 48 hours of the referral date. 6. During an interview with the Administrator on 7/28/21 at 3:30 PM, the Administrator confirmed the initial assessment visits were conducted, after 48 hours of the referral date.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: . A. Based on clinical record review, observation and interview during a home visit, Agency policy review and staff interview, it was determined the Agency failed to ensure the comprehensive assessment was accurate and/or complete. This was found in 1 of 1 (Pt. #1) active record reviewed, and 1 of 1 (Pt. #1) home visit conducted. Findings include: 1. Pt. #1. SOC 6/15/21. Diagnoses: Bilateral Primary Osteoarthritis of Knee and Essential (Primary) Hypertension. The clinical record was reviewed on 7/26/21 at 1:20 PM. The SOC comprehensive assessment completed by the SN and dated 6/15/21 included: "Someone must help the patient put on upper body clothing... Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes... Unable to get to and from the toilet but is able to use a bedside commode (with or without assistance)... Someone must help the patient to maintain toileting hygiene and/or adjust clothing... Able to walk only with the supervision of another person at all times... Able to feed self independently but requires: (a)meal set-up OR (B)INTERMITTENT ASSISTANCE OR SUPERVISION FROM ANOTHER PERSON or (c)a liquid, pureed or ground meat diet..." 2. A home visit was conducted with the Administrator on 7/27/21 at 3:15 PM. During the home visit, the Pt. introduced self and answered questions calmly and without delay or hesitation. Pt. was alert and oriented. Pt. stated lives alone in an independent living senior building. An observation was made of the patient's functional status and an interview was conducted with the Pt., regarding functional status 2 months ago compared with current functional status. The Pt. stated that 2 months ago and currently was/is able to independently put on upper and lower body clothing without assistance, use the toilet in the bathroom independentely, able to perform own toileting hygiene, uses a walker or cane to ambulate and do not need supervision of another person to walk/ambulate, able to feed self independently, and do not require someone to assist or set up meals. 3. During the same home visit on 7/27/21, Pt. #1 stated received the COVID-19 vaccine and presented the vaccination card. The card included documentation the Pt. received the first dose on 2/14/21, and the second dose on 3/3/21. The SOC comprehensive assessment dated 6/15/21 lacked documentation the Pt. had received the COVID-19 vaccines. 4. During a follow up telephone interview with the Pt. on 7/28/21 at 11:57 AM, regarding functional status 2 months ago and present status, Pt. #1 confirmed functional status as observed and stated during the home visit on 7/27/21. 5. The Agency policy titled, "Clinical Records" was reviewed on 7/28/21 at 2:00 PM. The policy required: "... e. The Admission Assessment contains pertinent patient... information... pertinent past medical history... functional abilities..." 6. During an interview with the Administrator on 7/28/21 at 11:57 AM, the Administrator stated the COVID-19 vaccination dates "should be part of the (comprehensive) assessment". During the same interview, the Administrator confirmed Pt. #1 comprehensive assessment was incomplete and inaccurate.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: . A. Based on clinical record review, observation and interview during home visit, Agency policy review and staff interview, it was determined the Agency failed to ensure the PsOC included all the medications and treatments; failed to ensure the POC was followed per physician orders; failed to ensure verbal orders were put in writing and authenticated; and failed to ensure physician was notified of Pts. not receiving ordered PT services. this has the potential to affect all Pts. receiving services. Findings Include: 1. In 3 of 6 clinical records reviewed wherein home visit conducted, the Agency failed to ensure the PsOC included all the medications and treatments accurately (G574). 2. In 3 of 6 clinical records reviewed, the Agency failed to ensure the POC was followed per physician orders (G578). 3. In 5 of 6 clinical records reviewed, the Agency failed to ensure verbal orders were put in writing and authenticated (G584). 4. In 3 of 6 clinical records reviewed, the Agency failed to ensure physician was notified of Pts. not receiving ordered PT services (G590). The cumulative effect of these systemic practices resulted in Agency's inability to provide care effectively and ensure Pts. received the care and services as required on the PsOC.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, observation and interview during a home visit and staff interview, it was determined the Agency failed to ensure the PsOC included all the medications and treatments accurately. This was found in 3 of 6 (Pts. #1, 2 and 3) clinical records reviewed. Findings include: 1. Pt. #1. SOC 6/15/21. Diagnoses: Bilateral Primary Osteoarthritis of Knee and Essential (Primary) Hypertension. The clinical record was reviewed on 7/26/21 at 1:20 PM. A home visit was conducted on 7/27/21 at 3:15 PM with the Administrator. During the home visit the patient's medications were on the dining room table. The medication bottle labeled: "Amlodipine Besylate 10 MG Tablets Take 1 Tablet by mouth daily" was observed. The Pt. stated has taken this medication for the past "10 years". The POC effective 6/15/21 lacked "Amlodipine Besylate". 2. Pt. #2. SOC 2/12/21. Diagnoses: Bilateral Primary Osteoarthritis of Hip and Unspecified Chronic Obstructive Pulmonary Disease. The closed clinical record was reviewed on 7/26/21 at 2:00 PM. The record contained the POC for the certification period of 2/12/21 to 4/12/21 requiring the Pt. to have the medication: "o2 at 2 liters per minute via nc. The POC lacked the frequency of the o2. The POC effective 2/12/21 included: "...SN to administer covid-19 vaccine..." During an interview with the Administrator on 7/28/21 at 11:57 AM. The Administrator stated: "I can't give the vaccine... I don't have access to the vaccine, it's an error". 3. Pt. #3. SOC 4/9/20. Diagnoses: Stage 2 Pressure Ulcer of Sacral Region. The closed clinical record was reviewed on 7/26/21 at 3:00 PM. The record contained the PsOC for the certification periods of 4/9/20 to 6/7/20 and 6/8/20 to 8/6/20, requiring the Pt. to have the medication: "O2 at 2 liters per minute via NC." The POC lacked the frequency of the O2. 4. During an interview with the Administrator on 7/28/21 at 11:57 AM, the above findings were confirmed.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the POC was followed per physician orders. This was found in 3 of 6 (Pts. #2, 4 and 5) clinical records reviewed. Findings include: 1. Pt. #2. SOC 2/12/21. Diagnoses: Bilateral Primary Osteoarthritis of Hip and Unspecified Chronic Obstructive Pulmonary Disease. The closed clinical record was reviewed on 7/26/21 at 2:00 PM. The record contained the Face-to-Face form signed by the Physician on 1/14/21 and faxed to the Agency on 1/25/21 which included: "Physical therapy - Evaluate, treat and manage patient for gait training..." The record lacked documentation that Physical therapy was offered, provided, and the Physician was notified the service was not provided. 2. Pt. #4. SOC 11/12/20. Diagnosis: Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 7/26/21 at 1:00 PM. The record included the Face-to-Face encounter dated 11/20/20 with order for (PT) physical therapy and (ST) speech therapy to evaluate and treat for functional deficit. The record lacked documentation of the Pt. receiving these services. No modification orders were found in the record. 3. Pt. #5. SOC 1/27/21. Diagnosis: Primary Generalized Osteoarthritis. The clinical record was reviewed on 7/26/21 at 2:15 PM. The record included the Face-to-Face encounter dated 12/01/20 with order for PT to do evaluation and establish home exercise program. The record lacked documentation of the Pt. receiving PT services. No modification orders were found in the record. 4. During an interview with the Administrator on 7/28/21 between 12:30 PM to 1:30 PM and 2:30 PM to 3:30 PM, the above findings were confirmed.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: 4. Pt. #4. SOC 11/12/20. Diagnosis: Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 7/26/21 at 1:00 PM. The record included the Face-to-Face encounter dated 11/20/20, faxed and signed by Physician on 11/16/20 with order for (PT) physical therapy and (ST) speech therapy to evaluate and treat for functional deficit. Verbal order received by RN to begin services was not written in the clinical record. During an interview with the Administrator on 7/28/21 at 1:30 PM, the Administrator stated she received a verbal order to start service on 11/20/20, and "didn't write the order". As of 7/26/21, the record lacked documentation the RN wrote the verbal order in the clinical record. 5. Pt. #5. SOC 1/27/21. Diagnosis: Primary Generalized Osteoarthritis. The clinical record was reviewed on 7/26/21 at 2:15 PM. The record included the Face-to-Face encounter dated 12/01/20 and signed by the Physician on 12/3/20 with order for PT to do evaluation and establish home exercise program. Verbal order received by RN to begin services was not written in the clinical record. During an interview with the Administrator on 7/28/21 at 1:45 PM, the Administrator stated she received a verbal order to start service on 12/1/20, and "didn't write the order". As of 7/26/21, the record lacked documentation the RN wrote the verbal order in the clinical record. 6. The Agency policy titled, "Physician's Plan Of Care / Change Orders" was reviewed on 7/29/21 at 10:00 AM. The policy required: "When the Plan of Care cannot be completed until after an evaluation visit, the physician's verbal orders shall be documented and constitute the Plan of Care until the plan is completed, signed and dated by the physician and returned to the Agency..." 7. During an interview with the Administrator on 7/28/21 between 12:30 PM to 1:30 PM and 2:30 PM to 3:30 PM, the Administrator confirmed the RN failed to put verbal orders in writing for Physician to review and authenticate. . A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure verbal orders were put in writing and authenticated in a timely manner. This was found in 5 of 6 (Pt. #1, 2, 3, 4, and 5) clinical records reviewed. Findings include: 1. Pt. #1. SOC 6/15/21. Diagnoses: Bilateral Primary Osteoarthritis of Knee and Essential (Primary) Hypertension. The clinical record was reviewed on 7/26/21 at 1:20 PM. The record contained the POC signed by the Physician on 7/5/21. The SOC comprehensive assessment form completed by the SN and dated 6/15/21, included a referral date of "06/14/2021". During an interview with the Administrator on 7/28/21 at 11:57 AM, the Administrator stated: "He (the Physician) called me to start service, but I did not write it." As of 7/26/21, the record lacked documentation the RN wrote the verbal order in the clinical record. 2. Pt. #2. SOC 2/12/21. Diagnoses: Bilateral Primary Osteoarthritis of Hip and Unspecified Chronic Obstructive Pulmonary Disease. The closed clinical record was reviewed on 7/26/21 at 2:00 PM. The record contained POC effective 2/12/21 signed by the Physician on 3/10/21. During an interview with the Administrator on 7/28/21 at 11:57 AM, the Administrator stated she received a verbal order to start service on 2/11/21, and "didn't write the order". As of 7/26/21, the record lacked documentation the RN wrote the verbal order in the clinical record. 3. Pt. #3. SOC 4/9/20. Diagnoses: Stage 2 Pressure Ulcer of Sacral Region. The closed clinical record was reviewed on 7/26/21 at 3:00 PM. The record contained the POC effective 2/12/21 signed by the Physician on 3/10/21. During an interview with the Administrator on 7/28/21 at 11:57 AM and 7/29/21 at 10:20 AM. The Administrator stated she received a verbal order to start service, but didn't remember the exact date and stated: "I didn't write it..."

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: . A. Based on clinical record review and staff interview, the Agency failed to ensure physician was notified of Pts. not receiving ordered PT services. This was found in 3 of 6 (Pts. #2, 4 and 5) clinical records reviewed. Findings Include: 1. Pt. #2. SOC 2/12/21. Diagnoses: Bilateral Primary Osteoarthritis of Hip and Unspecified Chronic Obstructive Pulmonary Disease. The closed clinical record was reviewed on 7/26/21 at 2:00 PM. The record contained the Face-to-Face form signed by the Physician on 1/14/21 and faxed to the Agency on 1/25/21 which included: "Physical therapy - Evaluate, treat and manage patient for gait training..." The record lacked documentation that Physical therapy was offered, provided, and physician notification of Pt. not receiving PT services. 2. Pt. #4. SOC 11/12/20. Diagnosis: Other Sequelae of Cerebral Infarction. The clinical record was reviewed on 7/26/21 at 1:00 PM. The record included the Face-to-Face encounter dated 11/20/20 with order for (PT) physical therapy and (ST) speech therapy to evaluate and treat for functional deficit. The record lacked documentation of the Pt. receiving these services, and physician notification of Pt. of not receiving PT services. 3. Pt. #5. SOC 1/27/21. Diagnosis: Primary Generalized Osteoarthritis. The clinical record was reviewed on 7/26/21 at 2:15 PM. The record included the Face-to-Face encounter dated 12/01/20 with order for PT to do evaluation and establish home exercise program. The record lacked documentation of the Pt. receiving PT services, and physician notification of Pt. not receiving PT services. 4. During an interview with the Administrator on 7/28/21 between 12:30 PM to 1:30 PM and 2:30 PM to 3:30 PM, the above findings were confirmed.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: . A. Based on review of the Agency Infection Control binder, Agency policy review and staff interview, it was determined the agency failed to implement and maintain a Surveillance program to identify, prevent, control, monitor and track of potential infectious diseases. This has the potential to affect staff providing services and Pts. receiving services. Findings Include: 1. The Agency failed to implement and maintain a Surveillance program to identify, prevent, control, monitor and track of potential infectious diseases. (G684). The cululitive effect of these systemic practices resulted in the Agency's inability to provide appropriate Infection Control services.

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: . A. Based on review of the Agency Infection Control Program, Agency Policy and staff interview, it was determined the Agency failed to implement and maintain a surveillance program to identify, prevent, control, monitor and track staff and Pts. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency's Infection Control binder was reviewed on 7/27/21 at 10:30 AM. The binder lacked any updated data related to infection control surveillance and Infection Control Logs tracking staff and Pt. infections. 2. The Agency's "Policy titled, "Infection Control Program" was reviewed on 7/27/21 at 11:00 AM. The "Policy included. "The goal of the surveillance, prevention and control of infection program is to improve client health outcomes through identification... and to reduce the risk of transmission of infectious agents, both potential and real, among clients, staff and other caregivers. It also includes strategies to reduce risk of infections... staff will track rates and trends, prioritize, implement and evaluate interventions, revise as needed and determine if programs goals are met." Reporting "The Agency supervisor or designee will keep current documentation of the infection control log for employees and clients... Prevention and Control "Staff members, clients and caregivers will be informed of any infection prevention or control precautions to be taken... Surveillance... Outbreak of infections related to a common organism which occurs among clients and staff... Identification...Written logs will be maintained by which reported infections, or signs/symptoms for suspected infections among employees and/or clients, will be documented. Tracking logs are maintained..." 3. During an interview with the Administrator on 728/21 at 3:45 PM, the Administrator stated surveillance procedures are not being followed and confirmed the above findings.

Skilled professional services CFR(s): 484.75 Condition of participation: Skilled professional services. Skilled professional services include skilled nursing services, physical therapy, speech-language pathology services, and occupational therapy, as specified in §409.44 of this chapter, and physician or allowed practitioner and medical social work services as specified in §409.45 of this chapter. Skilled professionals who provide services to HHA patients directly or under arrangement must participate in the coordination of care. This CONDITION is not met as evidenced by: . A. Based on Organizational chart review and staff interview, the Agency failed to ensure Nursing services are provided under the supervision of the Registered Nurse. This has the potential to affect all Pts. receiving skilled care services. Findings Include: 1. The Agency failed to ensure Nursing services are provided under the supervision of the Registered Nurse (G726). The cumulative effect of these systemic practices resulted in Agency's inability to provide Registered Nurse supervision of all Nursing services received by Pts.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: . A. Based on Organizational chart review and staff interview, the Agency failed to ensure Nursing services are provided under the supervision of the Registered Nurse. This has the potential to affect all Pts. receiving skilled care services. Findings Include: 1. Organizational Chart (undated) was reviewed on 7/26/21 at 10:00 AM. The chart documents the Agency Supervisor as," Verbally Resigned 7/23/21." While onsite from 7/26/21 (Entrance) to Exit (8/3/21), an Agency Supervisor was not available and/or present during the survey. The Administrator ( Registered Nurse), is the only listed RN on the chart. 2. During an interview with the Administrator on 7/26/21 at 2:00 PM," The Agency Supervisor just left and quit on 7/23/21. I am also a RN. I am the only RN with the Agency." The above findings were confirmed.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: . A. Based on review of clinical records and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 5 of 6 (Pts. #2, 3, 4, 5 and 6) closed/discharged clinical records reviewed. Findings include: 1. Pt. #2. SOC 2/12/21. Diagnoses: Bilateral Primary Osteoarthritis of Hip and Unspecified Chronic Obstructive Pulmonary Disease. The closed clinical record was reviewed on 7/26/21 at 2:00 PM. The record/agency lacked documentation the Agency had sent a copy of the Discharge Summary to the Physician. Pt. #2 was discharged on 4/5/21. 2. Pt. #3. SOC 4/9/20. Primary Diagnosis: Stage 2 Pressure Ulcer of Sacral Region. The closed clinical record was reviewed on 7/26/21 at 3:00 PM. The record/Agency lacked documentation the Agency had sent a copy of the Discharge Summary to the Physician. Pt. #3 was discharged on 8/5/20. 3. Pt. #4. SOC 11/12/20. Diagnosis: Other Sequelae of Cerebral Infarction. The closed/discharged clinical record was reviewed on 7/26/21 at 1:00 PM. The record/Agency lacked documentation the Agency had sent a copy of the Discharge Summary to the Physician. Pt. #4 was discharged on 1/7/21. 4. Pt. #5. SOC 1/27/21. Diagnosis: Primary Generalized Osteoarthritis. The closed/discharge clinical record was reviewed on 7/26/21 at 2:15 PM. The record/Agency lacked documentation the Agency had sent a copy of the Discharge Summary to the Physician. Pt. #5 was discharged on 2/27/21. 5. Pt. #6. SOC 3/12/21. Diagnosis: Bilateral Osteoarthritis of Knee. The closed/discharged clinical record was reviewed on 7/26/21 at 3:15 PM. The record/Agency lacked documentation the Agency had sent a copy of the Discharge Summary to the Physician. Pt. #7 was discharged on 4/9/21. 6. During an interview with the Administrator on 7/28/21 between 12:30 PM to 1:30 PM and 2:30 PM to 3:30 PM, the Administrator confirmed the Agency failed to provide documentation of the Discharge Summary sent to the attending Physician.