Every finding on record at Access Care Home Health Agency Inc

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview, record review and document review, the agency failed to ensure the comprehensive assessment was completed and signed by the visiting registered nurse (RN) within the required time frame for 1 of 2 sampled patients (Patient 2). The deficient practice had the potential for the agency failing to monitor the patient’s progress or decline and ensure the patient received an individualized written plan of care in a timely manner. Findings include: Patient 2 (P2) P2 was admitted on 07/25/2024, with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease, and heart failure. P2 was recertified for the period 03/22/2025 through 05/20/2025, and from 05/21/2025 to 07/19/2025. P2’s calendar of visits for the previous recertification period (03/22/2025 to 05/20/2025) documented a skilled nursing (SN) home visit was conducted on 05/16/2025 for the patient’s current recertification (05/21/2025 to 07/19/2025). P2’s medical record lacked documented evidence the comprehensive assessment for the current recertification period was completed and signed by the visiting RN. On 05/28/2025 at 1:09 PM, the RN who performed the SN home visit confirmed P2’s comprehensive assessment for the current recertification period had not been completed and signed by the RN. The RN indicated the home visit was conducted on 05/16/2025 and the comprehensive assessment or the OASIS (Outcome and Assessment Information Set) E1 – Recertification form should have been completed and signed within five days from the home visit or by 05/21/2025. The agency’s policy titled Follow-Up Comprehensive Assessment and OASIS Data Collection (undated), documented specific time points had been identified for completing comprehensive assessment and OASIS data collection and must have been collected during a home visit. They were: - Within five calendar days of each two-month interval after the Start of Care (SOC), in the last five days of the certification period; day 56, 57, 58, 59, 60. - Updated and revised as frequently as the patient’s status changed or condition required.

This Statement of Deficiencies was generated as a result of an Emergency Preparedness Survey for Home Health Agencies conducted at your agency from September 17, 2024 through September 27, 2024, in accordance with 42 CFR (Code of Federal Regulations) Part 484 - Home Health Services. The active census at the time of entry was 12 patients. Twelve clinical records were reviewed. Three home visits were conducted. The agency failed to maintain condition level compliance with the following Condition of Participation: -42 CFR Part 484.100: Emergency Preparedness The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] 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: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[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: Based on documentation review and interview, the agency failed to ensure it maintained condition level compliance with the emergency preparedness program. Findings include: Review of documentation revealed the agency failed to ensure it reviewed and updated its emergency preparedness plan at least every 2 years (E0004); failed to ensure it reviewed and updated its all-hazards risk assessment at least every 2 years (E0006); failed to ensure its emergency preparedness training and testing program was reviewed and updated at least every 2 years (E0036); failed to ensure its emergency preparedness training and testing program was implemented at hire and then at least every 2 years (E0037) and failed to ensure it conducted exercises to test its emergency plan at least every 2 years (E0039). The cumulative effect of these systemic practices resulted in the failure of the agency to ensure implementation of an emergency preparedness program.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(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: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness plan at least every 2 years. Findings include: The emergency preparedness plan provided by the agency, failed to show it was reviewed and updated at least every 2 years. On 9/17-18/2024, the acting Administrator was informed of the lack of documentation. The acting Administrator indicated the prep binder(s) included everything the agency had in this regard.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(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 Hospices at §418.113(a):] 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. *[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. 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):] 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. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its all-hazards risk assessment at least every 2 years. Findings include: Record review revealed the all-hazards approach risk assessment provided was undated and lacked documented evidence of a review/update in the last 2 years. On 9/17-18/2024, the acting Administrator was informed of the lack of documentation. The acting Administrator indicated the prep binder(s) included everything the agency had regarding Emergency Preparedness.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(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, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and 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 facilities 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: Based on record review and interview, the agency failed to ensure its emergency preparedness training and testing program was reviewed and updated, with employees receiving training on the updates at least every 2 years. Findings include: There was no documented evidence the agency reviewed and/or updated its emergency preparedness training and testing program at least every 2 years. On 9/17-18/2024, the acting Administrator was informed of the lack of documentation of the above review/update, and the acting Administrator indicated the prep binder(s) included everything the agency had regarding emergency preparedness.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure its emergency preparedness training program was implemented at hire and then reutilized every 2 years for employee retraining. Findings include: There was no documented evidence the agency ensured its emergency preparedness training program was implemented at hire and then reutilized at least every 2 years for employee training. On 9/17-18/2024, the acting Administrator was informed of the lack of documentation of the above review/update, and the acting Administrator indicated the prep binder(s) included everything the agency had regarding emergency preparedness training.

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 record review and interview, the agency failed to ensure it conducted exercises to test its emergency plan at least every two years. Findings include: There was no documented evidence the agency completed any of 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. On 9/17-18/2024, the acting Administrator was informed of the lack of documentation for testing of the emergency plan that was conducted. The acting Administrator indicated the prep binder(s) included everything the agency had regarding testing of the emergency plan.

This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey conducted at your agency from September 17, 2024, through September 27, 2024, in accordance with 42 CFR (Code of Federal Regulations) Part 484 - Home Health Services. The active census at the time of entry was 12 patients. Twelve clinical records were reviewed. Three home visits were conducted. The agency failed to maintain condition level compliance with the following Conditions of Participation: -42 CFR Part 484.44: Reporting OASIS Information -42 CFR Part 484.55: Comprehensive Assessment of Patients -42 CFR Part 484.65: Quality Assessment/Performance Improvement -42 CFR Part 484.100: Emergency Preparedness -42 CFR Part 484.105: Organization and Administration of Services -42 CFR Part 484.110: Clinical Records The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:

Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to maintain condition level compliance with reporting OASIS information. Findings include: Review of documentation revealed the agency failed to electronically transmit each completed OASIS assessment within 30 days of completing the assessment of the beneficiary for every quarter reviewed since its initial certification survey (G0372). The cumulative effect of this systemic practice resulted in the failure of the agency to ensure the timely completion and submission of statutorily mandated assessments of its patients.

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, interview and policy review, the agency failed to electronically transmit each completed OASIS assessment within 30 days of completing the assessment of the beneficiary for every quarter reviewed since its initial certification survey in March 2021. Findings include: According to the state's OASIS Education Coordinator in the pre-survey report, the agency was out of compliance due to late transmission of OASIS for 8 of 8 quarters reviewed since its initial certification survey in March 2021. The assessments submitted late for the nine quarters varied from a low of 16% to a high of 100% of all quarterly submissions. On 9/17/2024 at 9:05 AM, the acting Administrator confirmed the findings but indicated recent improvement at 16%. There was no explanation as to why submissions were repeatedly late. The OASIS Data Quality Audits policy provided revealed the purpose of performing OASIS quality audits was to ensure the accuracy of the OASIS data, to minimize data error and promote compliance. This was accomplished through: OASIS accuracy audits, data entry audits and clinical audit visits. There was no documented evidence the agency conducted any of the above audits for OASIS compliance.

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: Based on document review and interview, the agency failed to ensure it maintained condition level compliance with comprehensive assessments of patients. Findings include: Review of documentation revealed the agency failed to ensure its comprehensive assessments of patients were completed in a timely manner by failing to conduct and document an OASIS Start of Care assessment within five days of the first visit where the agency provided hands on, direct care services (G0520) and to conduct and document OASIS Transfer/Discharge assessments within two days of a patient's discharge date (G0550). The cumulative effect of these systemic practices resulted in the failure of the agency to ensure the timely completion of statutorily mandated assessments of its patients.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure it conducted and documented an OASIS Start of Care assessment within five days of the first visit where the agency provided hands on, direct care services for 1 of 12 patients (Patient #10). Findings include: Patient #10 On 8/19/2024, the agency admitted Patient #10 with chronic obstructive pulmonary disease. In anticipation of a skilled nursing visit on 9/18/2024, the clinical record was reviewed with the following anomalies identified: The start of care OASIS assessment (8/19/2024) was incomplete and printed out at 4:59 PM on 9/17/2024. The plan of care requested for the home visit was incomplete. Start of care orders were not entered. No skilled nursing visits were documented. On 8/19/2024, the agency certified Patient #10 from 8/19/2024 through 10/17/2024. On 8/19/2024, the incomplete plan of care revealed a physician ordered skilled nursing visits twice the first week and then weekly thereafter. On 9/18/2024, Patient #10 was selected for a home visit with a skilled nurse. On 9/19/2024 at noon, the acting Administrator was observed completing the start of care OASIS assessment when it was discovered in a second record review. The acting Administrator completed the document and submitted it to CMS at 8:11 PM on 9/18/2024, after the day the home visit was completed. The start of care orders were now entered and the plan of care was now completed as well. The acting Administrator confirmed that the skilled nursing visits were now being entered during the survey and signed with the dates and times of when the visits were conducted weeks before. The newly entered skilled nursing visits lacked documented evidence of homebound status for 8/23/2024, 8/26/2024 and 9/13/2024. The OASIS Data Quality Audits policy provided revealed the purpose of performing OASIS quality audits was to ensure the accuracy of the OASIS data, to minimize data error and promote compliance. This was accomplished through: OASIS accuracy audits, data entry audits and clinical audit visits. There was no documented evidence the agency conducted any of the above audits for Start of Care OASIS compliance.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure it conducted and documented OASIS Transfer/Discharge assessments within two days of a patient's discharge date for 2 of 12 patients (Patient #6 and #8). Findings include: Patient #6 On 7/5/2024, the agency admitted Patient #6 with hypertension. On 7/5/2024, the agency certified Patient #6 from 7/5/2024 through 9/2/2024. On 7/5/2024, the plan of care revealed a physician ordered skilled nursing visits once the first week, twice the second week and weekly thereafter. On 9/19/2024 at 1:00 PM, the following anomalies were identified during clinical record review: The clinical record had a recertification period dated 9/3/2024 through 11/1/2024. The clinical record lacked a recertification assessment but had a plan of care for the recertification period with ordered skilled nursing visits. The visit calendar was blank, meaning no skilled nursing visits were scheduled, conducted or documented for September 2024. The last skilled nursing visit conducted and documented was dated 8/30/2024. On 9/19/2024, the acting Administrator verbalized the patient was discharged. Review of patient's clinical record lacked documented evidence of discharge. On 9/24/2024 upon recapping the issues identified, it was discovered the acting Administrator entered a discharge order dated 8/30/2024, which was not in the record on 9/19/2024. Evidence in the visit calendar now revealed a discharge on 8/30/2024. A discharge OASIS assessment was now entered but incomplete dated 8/30/2024. The September visit calendar and plan of care were no longer present in the clinical record. On 9/24/2024 in the morning, the acting Administrator confirmed the findings, indicating the information was added during the survey period. There was no documented evidence any of the above additions/changes to the clinical record were identified with a correction or late entry designation. Patient #8 On 5/22/2024, the agency admitted Patient #8 with hypertension and chronic respiratory failure. On 5/22/2024, the agency certified Patient #8 from 5/22/2024 through 7/20/2024. On 5/22/2024, the plan of care revealed a physician ordered skilled nursing visits three times the first week, twice the second week and then weekly thereafter. On 7/20/2024, the agency recertified Patient #8 from 7/21/2024 through 9/18/2024. On 7/21/2024, the plan of care revealed a physician ordered skilled nursing visits twice the first week and then weekly thereafter. On 9/19/2024 at 1:30 PM, clinical record review was conducted and revealed there was no documented evidence the agency documented any ordered skilled nursing visits from the start of care dated 5/22/2024 to the present 9/19/2024. The acting Administrator indicated the patient had been in the hospital since 8/1/2024. A discharge OASIS was submitted and accepted on 8/31/2024. The acting Administrator indicated knowing the patients when asked how visits were documented weeks and months after they were conducted. The acting Administrator did not keep a notebook or have a technique to record pertinent data from specific visits, yet each blank skilled nursing visit was authenticated, dated and timed corresponding to the original date and time when the visits were conducted. The OASIS Data Quality Audits policy provided revealed the purpose of performing OASIS quality audits was to ensure the accuracy of the OASIS data, to minimize data error and promote compliance. This was accomplished through: OASIS accuracy audits, data entry audits and clinical audit visits. There was no documented evidence the agency conducted any of the above audits for OASIS Transfer/Discharge assessment compliance.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure ordered skilled visits were conducted as ordered for 2 of 12 patients (Patient #1 and #5) and failed to ensure ordered services were delivered as ordered for 1 of 12 patients (Patient #9). Findings include: Patient #1 On 7/10/2024, the agency admitted Patient #1 with respiratory failure. On 7/10/2024, the agency certified Patient #1 from 7/10/2024 through 9/7/2024. On 7/10/2024, the plan of care revealed a physician ordered twice in one month skilled speech therapy visits. On 9/17/2024, clinical record review revealed speech therapy visits conducted and documented on 7/10/2024 and 8/6/2024. On 9/17/2024, the clinical record lacked documented evidence a physician changed, discontinued or otherwise modified the ordered frequency. On 9/17/2024 in the afternoon, the acting Administrator confirmed the therapy visits were conducted in two different months. Patient #5 On 2/24/2024, the agency admitted Patient #5 with encephalopathy. On 2/24/2024, the agency certified Patient #5 from 2/24/2024 through 3/18/2024. On 2/24/2024, the plan of care revealed a physician ordered three skilled nursing visits for the week of 2/25/2024 to 3/2/2024. On 9/17/2024, the clinical record lacked documented evidence of an order change, discontinuation, missed visit or other frequency modification. On 9/17/2024, the clinical record lacked documented evidence the skilled nursing visits were conducted and documented. On 9/17/2024 in the afternoon, the acting Administrator confirmed the findings. Patient #9 On 5/1/2024, the agency admitted Patient #9 with osteoporosis. On 5/1/2024, the agency certified Patient #9 from 5/1/2024 through 6/29/2024. On 5/1/2024, the plan of care revealed a physician ordered skilled nursing visits twice the first week and then weekly. On 5/1/2024, the plan of care revealed a physician ordered skilled assessment and observation of all body systems. On 5/1/2024, a physician order revealed an order for oxygen saturation level every visit. On 5/3/2024, a skilled nursing visit was conducted and documented without a skin assessment and oxygen saturation level. On 5/8/2024, a skilled nursing visit was conducted and documented without a skin assessment. On 9/17/2024 in the afternoon, the acting Administrator indicated forgetting to complete the above assessment areas.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure it maintained an accurate medication profile for 2 of 12 patients (Patient #1 and #10). Findings include: Patient #1 On 7/10/2024, the agency admitted Patient #1 with respiratory failure. On 9/3/2024, the agency recertified Patient #1 with hypertension from 9/8/2024 through 11/6/2024. On 9/8/2024, the plan of care revealed a physician ordered weekly skilled nursing visits. On 9/18/2024 in the morning, a home visit was conducted with a registered nurse. The following anomalies were identified within the medication profile at the group home with the proprietor: Aspirin 81 milligrams was discontinued but was listed on the medication profile provided. Metoprolol extended release 25 milligrams daily was reduced to a half tablet daily as of 8/26/2024. Haloperidol 5 milligrams at bedtime nightly was not listed on the medication profile provided. The container showed a new prescription filled as of 8/26/2024. The proprietor indicated the patient had taken it for a long time regularly. On 9/18/2024 after the visit, the registered nurse did not have an explanation as to why the medication profile was not updated. The Medication Administration policy provided revealed a medication profile would be updated as indicated and reviewed at least every 60 days. The medication profile provided revealed every medication listed was dated with the start of care date of 7/10/2024, meaning there was no 60 day review at the time of recertification on 9/3/2024. Patient #10 On 8/19/2024, the agency admitted Patient #10 with chronic obstructive pulmonary disease. On 8/19/2024, the agency certified Patient #10 from 8/19/2024 through 10/17/2024. On 9/18/2024, a home visit was conducted with a registered nurse. On 9/18/2024 at 10:20 AM, the group home proprietor revealed the following medication additions: Aspirin 81 milligrams daily as of 9/9/2024, Vitamin B-12 daily as of 9/9/2024, Farxiga 10 milligrams daily as of 9/10/2024, Metoprolol Tartrate 25 milligram tablet twice daily as of 9/10/2024, Furosemide 40 milligrams daily as of 9/11/2024, Potassium 10 milliequivalent daily as of 9/10/2024 and Spiriva Inhaler. The medication administration record and the medication profile lacked documented evidence of all medications listed above. The last dated addition to the medication profile was dated 8/19/2024, which was the start of care. When the registered nurse was questioned about the differences, the registered nurse checked the medication administration record and began taking notes as to the changes. On 9/18/2024 after the visit, the registered nurse did not have an explanation as to why the medication profile was not updated. The Medication Administration policy provided revealed a medication profile would be updated as indicated and reviewed at least every 60 days.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on document and policy review, the agency failed to maintain condition level compliance with the quality and performance improvement program. Findings include: On 09/17/2024, the agency failed to ensure its quality and performance improvement program demonstrated the following: The measuring, analysis and tracking of quality indicators, including adverse patient events, and other aspects of performance, enabling the agency to assess processes of care, services, and operations (G0642). The quality program utilized quality indicator data in its design and the data collected to monitor quality of care effectiveness (G0644). The quality program tracked adverse patient events, analyzed their causes, and implemented preventive actions (G0654). The quality program took actions aimed at performance improvement, implemented those actions, measured its success and tracked performance to ensure improvements were sustained (G0656). The quality program conducted and documented any performance improvement projects (G0658). The Governing Body failed to ensure an ongoing program for quality and performance improvement (G0660). The cumulative effect of these systemic practices resulted in the failure of the agency to ensure statutorily mandated care to its patients and a failure to monitor and improve its care to its patients.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it measured, analyzed, and tracked quality indicators, including adverse patient events, and other aspects of performance, enabling the agency to assess processes of care, services, and operations. Findings include: From 9/17-24/2024, the quality and performance improvement plan was reviewed. The plan lacked documented evidence anyone directed or participated in the plan. The acting administrator indicated whatever was contained within the quality binder was what the agency had as far as quality and performance improvement. There was no documented evidence of ongoing measuring, analyzing, and tracking of quality indicators, including adverse patient events, and other aspects of performance, enabling the agency to assess processes of care, services, and operations.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure its quality program utilized quality indicator data in its design and the data collected to monitor quality of care effectiveness. Findings include: From 9/17-24/2024, the quality and performance improvement plan was reviewed. There was no documented evidence anyone directed or participated in the plan. The acting administrator indicated whatever was contained within the quality binder was what the agency had as far as quality and performance improvement. There was no documented evidence of ongoing utilization of quality indicator data in the quality program design and using the data collected to monitor quality of care effectiveness.

Track adverse patient events CFR(s): 484.65(c)(2) Performance improvement activities must track adverse patient events, analyze their causes, and implement preventive actions. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it tracked adverse patient events, analyzed their causes, and implemented preventive actions. Findings include: From 9/17-24/2024, the quality and performance improvement plan was reviewed. There was no documented evidence anyone directed or participated in the plan. The acting administrator indicated whatever was contained within the quality binder was what the agency had as far as quality and performance improvement. There was no documented evidence of ongoing tracking of adverse patient events, analysis of causes and implementation of preventive actions.

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure it took actions aimed at performance improvement, implemented those actions, measured its success and tracked performance to ensure improvements were sustained. Findings include: From 9/17-24/2024, the quality and performance improvement plan was reviewed. There was no documented evidence anyone directed or participated in the plan. The acting administrator indicated whatever was contained within the quality binder was what the agency had as far as quality and performance improvement. There was no documented evidence of ongoing performance improvement actions implemented, measured and tracked to ensure sustained improvements.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it conducted and documented any performance improvement projects. Findings include: From 9/17-24/2024, the quality and performance improvement plan was reviewed. There was no documented evidence anyone directed or participated in the plan. The acting administrator indicated whatever was contained within the quality binder was what the agency had as far as quality and performance improvement. There was no documented evidence of ongoing performance improvement projects.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency's Governing Body failed to ensure an ongoing program for quality and performance improvement. Findings include: Despite a defined quality and performance improvement plan, there was no documented evidence: (1) That an ongoing program for quality improvement and patient safety was implemented and maintained; and (2) That the agency-wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions were evaluated for effectiveness. From 9/17-24/2024, the quality and performance improvement plan was reviewed, but there was no documented evidence anyone directed or participated in the plan. The acting administrator indicated whatever was contained within the quality binder was what the agency had as far as quality and performance improvement.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure clinical notes were prepared, documented and authenticated in a timely manner for 5 of 12 patients (Patient #6, #7, #8, 10 and #12). Findings include: Patient #6 On 7/5/2024, the agency admitted Patient #6 with hypertension. On 7/5/2024, the agency certified Patient #6 from 7/5/2024 through 9/2/2024. On 7/5/2024, the plan of care revealed a physician ordered skilled nursing visits once the first week, twice the second week and weekly thereafter. On 9/19/2024 at 1:00 PM, the following anomalies were identified during clinical record review: The clinical record had a recertification period dated 9/3/2024 through 11/1/2024. The clinical record lacked a recertification assessment but had a plan of care for the recertification period with ordered skilled nursing visits. The visit calendar was blank, meaning no skilled nursing visits were scheduled, conducted or documented for September 2024. The last skilled nursing visit conducted and documented was dated 8/30/2024. On 9/19/2024, the acting Administrator stated the patient was discharged. Review of the patient's clinical record lacked documented evidence of a discharge. On 9/24/2024 upon recapping the issues identified, it was discovered the acting Administrator entered a discharge order dated 8/30/2024, which was not in the record on 9/19/2024. Evidence in the visit calendar now revealed a discharge on 8/30/2024. A discharge OASIS assessment was now entered but incomplete dated 8/30/2024. The September visit calendar and plan of care were no longer present in the clinical record. On 9/24/2024 in the morning, the acting Administrator confirmed the findings, indicating the information was added during the survey period. There was no documented evidence any of the above additions/changes to the clinical record were identified with a correction or late entry designation. Patient #7 On 7/25/2024, the agency admitted Patient #7 with paroxysmal atrial fibrillation. On 7/25/2024, the plan of care showed the agency conducted and documented weekly physical therapy visits. On 9/20/2024, record review identified a physical therapist documented an incomplete physical therapy reassessment dated 8/24/2024. The acting Administrator was asked several times during the survey to facilitate an interview with the physical therapist. The acting Administrator indicated it was a discharge. The acting Administrator failed to secure the interview with the physical therapist. By 9/24/2024, the physical therapist had removed the reassessment and instead documented a physical therapy discharge dated 8/24/2024. The reassessment and discharge documents were indistinguishable from each other regarding the date and time of the original visit, which was 3:00 PM on 8/24/2024. There was no correction or late entry designation. On 9/24/2024, the acting Administrator indicated the therapist entered the physical therapy discharge. The agency did not provide a policy regarding correcting clinical records or making late entries. On 7/25/2024, the plan of care revealed a physician ordered skilled nursing visits once the first week, twice the second week and then weekly thereafter. On 9/24/2024, a clinical record review revealed the entire certification period had all ordered skilled nursing visits plotted on the visit calendar, but all the visit notes were blank. The acting Administrator was observed trying to fill in the data from the visits during the survey. The Acting Administrator did not keep a notebook or some other technique of recording key data of visits aside from vital signs. The skilled nursing visit sheets were all electronically authenticated from dates/times of the actual visits with no data entered. The acting Administrator kept vital signs logs in the residences of patients and took pictures of the logs with a personal phone when the logs were filled with multiple visits. An agency phone was available for this purpose, but the acting Administrator did not want the absent Administrator to know this was occurring in order to facilitate bulk entries of skilled visits at later dates. Patient #8 On 5/22/2024, the agency admitted Patient #8 with hypertension and chronic respiratory failure. On 5/22/2024, the agency certified Patient #8 from 5/22/2024 through 7/20/2024. On 5/22/2024, the plan of care revealed a physician ordered skilled nursing visits three times the first week, twice the second week and then weekly thereafter. On 7/20/2024, the agency recertified Patient #8 from 7/21/2024 through 9/18/2024. On 7/21/2024, the plan of care revealed a physician ordered skilled nursing visits twice the first week and then weekly thereafter. On 9/19/2024 at 1:30 PM, clinical record review was conducted and revealed there was no documented evidence the agency documented any ordered skilled nursing visits from the start of care dated 5/22/2024, to the present 9/19/2024. The acting Administrator indicated the patient had been in the hospital since 8/1/2024. A discharge OASIS was submitted and accepted on 8/31/2024. The acting Administrator indicated knowing the patients when asked how visits were documented weeks and months after they were conducted. The acting Administrator did not keep a notebook or have a technique to record pertinent data from specific visits, yet each blank skilled nursing visit was authenticated, dated and timed corresponding to the original date and time when the visits were conducted. Patient #10 On 8/19/2024, the agency admitted Patient #10 with chronic obstructive pulmonary disease. In anticipation of a skilled nursing visit on 9/18/2024, the clinical record was reviewed with the following anomalies identified: The start of care OASIS assessment (8/19/2024) was incomplete and printed out at 4:59 PM on 9/17/2024. The plan of care requested for the home visit was incomplete. Start of care orders were not entered. No skilled nursing visits were documented. On 8/19/2024, the agency certified Patient #10 from 8/19/2024 through 10/17/2024. On 8/19/2024, the incomplete plan of care revealed a physician ordered skilled nursing visits twice the first week and then weekly thereafter. On 9/18/2024, Patient #10 was selected for a home visit with a skilled nurse. On 9/19/2024 at noon, the acting Administrator was observed completing the start of care OASIS assessment when it was discovered in a second record review. The acting Administrator completed the document and submitted it to CMS at 8:11 PM on 9/18/2024, after the day the home visit was completed. The start of care orders were now entered and the plan of care was now completed as well. The acting Administrator confirmed that the skilled nursing visits were now being entered during the survey and signed with the dates and times of when the visits were conducted weeks before. The newly entered skilled nursing visits lacked documented evidence of homebound status for 8/23/2024, 8/26/2024 and 9/13/2024. Patient #12 On 5/30/2024, the agency admitted Patient #12 with acute chronic obstructive pulmonary disease. The agency certified the patient from 5/30/2024 through 7/28/2024. On 5/30/2024, the plan of care revealed a physician ordered skilled nursing visits once the first week, twice the second week and then weekly thereafter. On 7/27/2024, the agency recertified Patient #12 with essential hypertension. The agency recertified the patient from 7/29/2024 through 9/26/2024. On 7/29/2024, the plan of care revealed a physician ordered weekly skilled nursing visits. The clinical record lacked documented evidence of any skilled nursing visits for either certification period. On 9/19/2024 at 1:30 PM, clinical record review was conducted and revealed there was no documented evidence the agency documented any ordered skilled nursing visits or missed visits from the start of care to the present 9/19/2024. The acting Administrator indicated the patient had been in the hospital since 8/1/2024. The acting Administrator indicated knowing the patients when asked how visits were documented weeks and months after they were conducted. The acting Administrator did not keep a notebook or have a technique to record pertinent data from specific visits. The visit calendar lacked documented evidence skilled nursing visits were even plotted and scheduled to be conducted since the start of care. At a later point in the survey, the acting Administrator continued silently entering skilled nursing visits for 7/31/2024 and 8/7/2024. The acting Administrator was confronted and admitted documenting these two skilled nursing visits, even though they were conducted in the previous months. The acting Administrator verbalized missed visits for 6/8/2024, 7/2/2024, 8/3/2024, 8/14/2024 and 8/21/2024, even though none of these visits were plotted and scheduled on the corresponding visit calendar. The clinical record lacked documented evidence a physician changed, discontinued or otherwise modified the visit frequency for skilled nursing visits in either certification period. The acting Administrator entered a discharge order due to not being able to locate the patient and backdated the order to 8/28/2024. None of the above documentation was accompanied by any indication of a correction or late entry. The Confidentiality of Client Information policy revealed initials may be used on designated forms to indicate review, revisions, or correction of entry. The Clinical Records and Maintenance policy provided revealed clinical notes were written the day of service delivery and incorporated into the clinical record at least weekly.

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 ensure any skilled professional, regardless of whether the skilled professional was a direct employee or contractor of the agency, contributed to all phases of the QAPI program. Findings include: From 9/17-24/2024, the acting Administrator provided a quality and performance improvement plan. The plan lacked documented evidence anyone directed or participated in the plan. The acting administrator indicated whatever was contained within the quality binder was what the agency had as far as quality and performance improvement.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on document review and interview, the agency failed to maintain condition level compliance with the organization and administration of services. Findings include: Document review completed during the onsite survey revealed the agency failed to ensure its governing body (or designated persons so functioning) assumed full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, and its quality assessment and performance improvement program (G0942) and failed to ensure its acting Administrator acted responsibly for all day-to-day operations of the agency (G0948). The cumulative effect of these systemic practices resulted in the failure of the agency to deliver statutorily mandated care to its patients.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review, interview and policy review, the Governing Body failed to take responsibility for the agency's overall management and operation, provision of all home health services and its quality and performance improvement program. Findings include: On 9/17/2024 after the agency was open for business at 9:00 AM, there was nobody at the agency. It took nearly an hour for the surveyor to confirm contact information and get into contact with a registered nurse who finally responded. The registered nurse turned out to be the acting administrator and the clinical director and was conducting a home skilled nursing visit. The surveyor waited another 20-30 minutes for the registered nurse to arrive. The purpose of the visit was explained to the acting administrator who indicated the agency was not ready to be recertified. The agency consisted solely of the visiting registered nurse who served as the clinical director as well as the acting administrator. The administrator appointed the clinical director as acting administrator indefinitely due to returning to the home country to care for an elderly relative. The appointment was in writing and dated January 2024. The only other employee was a home health aide who was called upon when needed. All therapy services were contracted. Essentially, the agency operated with one person administratively and as caregiver to all patients. The acting Administrator failed to do the following as Governing Body representative: - Employ qualified personnel and arrange for their orientation and continuing education. -Oversee the Quality and Performance Improvement program to ensure the program was being implemented and continually maintained. -Oversee the OASIS assessments/submissions and complete timely patient care documentation. -Complying with applicable law and regulations of home health agency operations. The agency did not have another Registered Nurse available. The Administrator (50% owner) allowed the acting administrator/clinical director to operate the agency independently while still employed elsewhere. The last documented Governing Body meeting, dated 1/2/2024, showed the Governing Body consisted of two 50%, non-participating owners. The third person was overseas indefinitely and was the Administrator, meaning one person acted and operated the agency as acting administrator, clinical director, quality director and visiting nurse. The acting Administrator was not accountable to anyone. The acting Administrator claimed weekly conversations with the Administrator/owner, but there was nothing documented. The acting Administrator, functioning as a visit nurse, had visit route sheets missing several visits of Patient #8. The acting Administrator electronically signed documentation, created, updated and deleted documentation for multiple patients during the survey. Governing Body Bylaws and Rules and regulations were requested, but the agency did not provide them or have them available. The Professional Advisory Committee policy revealed the committee would meet quarterly, or more often as needed, and minutes of each meeting would be recorded and clinical records would be reviewed. There was no documented evidence of such a committee. The agency's latest annual approval of policies and procedures showed a review date of 1/2/2024, which coincided with the last Governing Body meeting. There was no documented evidence anyone reviewed plans of care and clinical records. The acting Administrator did not attempt to contact either the Administrator or a consultant for assistance during the survey.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency's Administrator did not demonstrate responsibility for all day-to-day operations of the agency. Findings include: On 9/17/2024 after the agency was open for business at 9:00 AM, there was nobody at the agency. It took nearly an hour for the surveyor to confirm contact information and get into contact with a registered nurse who responded. The registered nurse turned out to be the acting administrator and the clinical director and was conducting a home skilled nursing visit. The surveyor waited another 20-30 minutes for the registered nurse to arrive. The purpose of the visit was explained to the acting administrator who indicated the agency was not ready to be recertified. The agency consisted solely of the visiting registered nurse who served as the clinical director as well as the acting administrator. The administrator appointed the clinical director as acting administrator indefinitely due to returning to the home country to care for an elderly relative. The appointment was in writing and dated January 2024. The only other employee was a home health aide who was called upon when needed. All therapy services were contracted. Essentially, the agency operated with one person administratively and as caregiver to all patients. The acting Administrator failed to do the following as Governing Body representative: - Employ qualified personnel and arrange for their orientation and continuing education. -Oversee the Quality and Performance Improvement program to ensure the program was being implemented and continually maintained. -Oversee the OASIS assessments/submissions and complete, timely patient care documentation. -Complying with applicable law and regulations of home health agency operations. The agency did not have another Registered Nurse available. The Administrator (50% owner) allowed the acting administrator/clinical director to operate the agency independently while still employed elsewhere. The last documented Governing Body meeting, dated 1/2/2024, showed the Governing Body consisted of two 50%, non-participating owners. The third person was overseas indefinitely and was the Administrator, meaning one person acted and operated the agency as acting administrator. clinical director, quality director and visiting nurse. The acting Administrator was not accountable to anyone. The acting Administrator claimed weekly conversations with the Administrator/owner, but there was nothing documented. The acting Administrator, functioning as a visit nurse, had visit route sheets missing several visits of Patient #8. The acting Administrator electronically signed documentation, created, updated and deleted documentation for multiple patients during the survey. Governing Body Bylaws and Rules and regulations were requested, but the agency did not provide them or have them available. The Professional Advisory Committee policy revealed the committee would meet quarterly, or more often as needed, and minutes of each meeting would be recorded and clinical records would be reviewed. There was no documented evidence of such a committee. The agency's latest annual approval of policies and procedures showed a review date of 1/2/2024, which coincided with the last Governing Body meeting. There was no documented evidence anyone reviewed plans of care and clinical records. The acting Administrator did not attempt to contact either the Administrator or a consultant for assistance during the survey.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on observation, record review and interview, the agency failed to maintain compliance with conditions for participation for complete and accurate clinical records regarding visits, plans of care, and policy enforcement for securing patient information. Findings include: Review of clinical records and interview revealed the agency failed to ensure the patient's clinical record contained accurate, complete clinical visit notes and plans of care (G1012); failed to ensure clinical record entries included ordered treatments, services and patient responses to interventions (G1014); failed to ensure complete goals, orders and treatments were included in a plan of care (G1016); failed to ensure completion of a discharge summary (G1022); failed to ensure all clinical record entries were complete, and appropriately authenticated, dated, and timed (G1024); and failed to ensure the awareness, development and enforcement of policies and procedures to effectively protect and secure patient information, regarding the use of a personal electronic device to photograph vital signs in patient residences (G1028). The cumulative effect of these systemic practices resulted in the failure of the agency to ensure statutorily mandated care to its patients.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure patient clinical information was documented and authenticated in a timely manner for 6 of 12 patients (Patient #6, #7, #8, #10, #11 and #12). Findings include: Patient #6 On 7/5/2024, the agency admitted Patient #6 with hypertension. On 7/5/2024, the agency certified Patient #6 from 7/5/2024 through 9/2/2024. On 7/5/2024, the plan of care revealed a physician ordered skilled nursing visits once the first week, twice the second week and weekly thereafter. On 9/19/2024 at 1:00 PM, the following anomalies were identified during clinical record review: The clinical record had a recertification period dated 9/3/2024 through 11/1/2024. The clinical record lacked a recertification assessment but had a plan of care for the recertification period with ordered skilled nursing visits. The visit calendar was blank, meaning no skilled nursing visits were scheduled, conducted or documented for September 2024. The last skilled nursing visit conducted and documented was dated 8/30/2024. On 9/19/2024, the acting Administrator stated the patient was discharged, despite no documented evidence in the clinical record. On 9/24/2024 upon recapping the issues identified, it was discovered the acting Administrator entered a discharge order dated 8/30/2024, which was not in the record on 9/19/2024. Evidence in the visit calendar now revealed a discharge on 8/30/2024. A discharge OASIS assessment was now entered but incomplete dated 8/30/2024. The September visit calendar and plan of care were no longer present in the clinical record. On 9/24/2024 in the morning, the acting Administrator confirmed the findings, indicating the information was added during the survey period. There was no documented evidence any of the above additions/changes to the clinical record were identified with a correction or late entry designation. Patient #7 On 7/25/2024, the agency admitted Patient #7 with paroxysmal atrial fibrillation. On 7/25/2024, the plan of care showed the agency conducted and documented weekly physical therapy visits. On 9/20/2024, record review identified a physical therapist documented an incomplete physical therapy reassessment dated 8/24/2024. The acting Administrator was asked several times during the survey to facilitate an interview with the physical therapist. The acting Administrator indicated it was a discharge. The acting Administrator failed to secure the interview with the physical therapist. By 9/24/2024, the physical therapist had removed the reassessment and instead documented a physical therapy discharge dated 8/24/2024. The reassessment and discharge documents were indistinguishable from each other regarding the date and time of the original visit, which was 3:00 PM on 8/24/2024. There was no correction or late entry designation. On 9/24/2024, the acting Administrator indicated the therapist entered the physical therapy discharge. The agency did not provide a policy regarding correcting clinical records or making late entries. On 7/25/2024, the plan of care revealed a physician ordered skilled nursing visits once the first week, twice the second week and then weekly thereafter. On 9/24/2024, a clinical record review revealed the entire certification period had all ordered skilled nursing visits plotted on the visit calendar, but all the visit notes were blank. The acting Administrator was observed trying to fill in the data from the visits during the survey. The Acting Administrator did not keep a notebook or some other technique of recording key data of visits aside from vital signs. The skilled nursing visit sheets were all electronically authenticated from dates/times of the actual visits with no data entered. The acting Administrator kept vital signs logs in the residences of patients and took pictures of the logs with a personal phone when the logs were filled with multiple visits. An agency phone was available for this purpose, but the acting Administrator did not want the absent Administrator to know this was occurring to facilitate bulk entries of skilled visits at later dates. Patient #8 On 5/22/2024, the agency admitted Patient #8 with hypertension and chronic respiratory failure. On 5/22/2024, the agency certified Patient #8 from 5/22/2024 through 7/20/2024. On 5/22/2024, the plan of care revealed a physician ordered skilled nursing visits three times the first week, twice the second week and then weekly thereafter. On 7/20/2024, the agency recertified Patient #8 from 7/21/2024 through 9/18/2024. On 7/21/2024, the plan of care revealed a physician ordered skilled nursing visits twice the first week and then weekly thereafter. On 9/19/2024 at 1:30 PM, an extensive clinical record review was conducted and revealed there was no documented evidence the agency documented any ordered skilled nursing visits from the start of care dated 5/22/2024 to the present 9/19/2024. The acting Administrator indicated the patient had been in the hospital since 8/1/2024. A discharge OASIS was submitted and accepted on 8/31/2024. The acting Administrator indicated knowing the patients when asked how visits were documented weeks and months after they were conducted. The acting Administrator did not keep a notebook or have a technique to record pertinent data from specific visits, yet each blank skilled nursing visit was authenticated, dated and timed corresponding to the original date and time when the visits were conducted. Patient #10 On 8/19/2024, the agency admitted Patient #10 with chronic obstructive pulmonary disease. In anticipation of a skilled nursing visit on 9/18/2024, the clinical record was reviewed with the following anomalies identified: The start of care OASIS assessment (8/19/2024) was incomplete and printed out at 4:59 PM on 9/17/2024. The plan of care requested for the home visit was incomplete. Start of care orders were not entered. No skilled nursing visits were documented. On 8/19/2024, the agency certified Patient #10 from 8/19/2024 through 10/17/2024. On 8/19/2024, the incomplete plan of care revealed a physician ordered skilled nursing visits twice the first week and then weekly thereafter. On 9/18/2024, Patient #10 was selected for a home visit with a skilled nurse. On 9/19/2024 at noon, the acting Administrator was observed completing the start of care OASIS assessment when it was discovered in a second record review. The acting Administrator completed the document and submitted it to CMS at 8:11 PM on 9/18/2024, after the day the home visit was completed. The start of care orders were now entered and the plan of care was now completed as well. The acting Administrator confirmed that the skilled nursing visits were now being entered during the survey and signed with the dates and times of when the visits were conducted weeks before. The newly entered skilled nursing visits lacked documented evidence of homebound status for 8/23/2024, 8/26/2024 and 9/13/2024. Patient #11 On 8/7/2024, the agency admitted Patient #11 with generalized osteoarthritis. On 8/7/2024, the plan of care revealed a physician ordered skilled nursing visits twice the first week and then weekly thereafter. On 9/18/2024, the clinical record revealed every weekly skilled nursing visit lacked documented evidence of homebound status from 8/10/2024 through 9/12/2024. On 9/19/2024, a home visit was conducted with a registered nurse. The registered nurse documented home bound status in the clinical note for 9/19/2024. The registered nurse did not have an answer as to why homebound status was not documented for prior visits aside from forgetting to document. Patient #12 On 5/30/2024, the agency admitted Patient #12 with acute chronic obstructive pulmonary disease. The agency certified the patient from 5/30/2024 through 7/28/2024. On 5/30/2024, the plan of care revealed a physician ordered skilled nursing visits once the first week, twice the second week and then weekly thereafter. On 7/27/2024, the agency recertified Patient #12 with essential hypertension. The agency recertified the patient from 7/29/2024 through 9/26/2024. On 7/29/2024, the plan of care revealed a physician ordered weekly skilled nursing visits. The clinical record lacked documented evidence of any skilled nursing visits for either certification period. On 9/19/2024 at 1:30 PM, clinical record review revealed there was no documented evidence the agency documented any ordered skilled nursing visits or missed visits from the start of care to the present 9/19/2024. The acting Administrator indicated the patient had been in the hospital since 8/1/2024. The acting Administrator indicated knowing the patients when asked how visits were documented weeks and months after they were conducted. The acting Administrator did not keep a notebook or have a technique to record pertinent data from specific visits. The visit calendar lacked documented evidence skilled nursing visits were even plotted and scheduled to be conducted since the start of care. At a later point in the survey, the acting Administrator continued attempting to circumvent the surveyor by silently entering skilled nursing visits for 7/31/2024 and 8/7/2024. The acting Administrator was confronted and admitted documenting these two skilled nursing visits, even though they were conducted in the previous months. The acting Administrator verbalized missed visits for 6/8/2024, 7/2/2024, 8/3/2024, 8/14/2024 and 8/21/2024, even though none of these visits were plotted and scheduled on the corresponding visit calendar. The clinical record lacked documented evidence a physician changed, discontinued or otherwise modified the visit frequency for skilled nursing visits in either certification period. The Clinical Records and Maintenance policy provided revealed clinical notes were written the day of service delivery and incorporated into the clinical record at least weekly.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure clinical record entries included ordered treatments, services and patient responses to interventions for 4 of 12 patients (Patient #7, #8, #10 and #12). Findings include: Patient #7 On 7/25/2024, the agency admitted Patient #7 with paroxysmal atrial fibrillation. On 7/25/2024, the plan of care showed the agency conducted and documented weekly physical therapy visits. On 9/20/2024, record review identified a physical therapist documented an incomplete physical therapy reassessment dated 8/24/2024. The acting Administrator was asked several times during the survey to facilitate an interview with the physical therapist. The acting Administrator indicated it was a discharge. The acting Administrator failed to secure the interview with the physical therapist. By 9/24/2024, the physical therapist had removed the reassessment and instead documented a physical therapy discharge dated 8/24/2024. The reassessment and discharge documents were indistinguishable from each other regarding the date and time of the original visit, which was 3:00 PM on 8/24/2024. There was no correction or late entry designation. On 9/24/2024, the acting Administrator indicated the therapist entered the physical therapy discharge. The agency did not provide a policy regarding correcting clinical records or making late entries. On 7/25/2024, the plan of care revealed a physician ordered skilled nursing visits once the first week, twice the second week and then weekly thereafter. On 9/24/2024, a clinical record review revealed the entire certification period had all ordered skilled nursing visits plotted on the visit calendar, but all the visit notes were blank. The acting Administrator was caught trying to fill in the data from the visits during the survey. The Acting Administrator did not keep a notebook or some other technique of recording key data of visits aside from vital signs. The skilled nursing visit sheets were all electronically authenticated from dates/times of the actual visits with no data entered. The acting Administrator kept vital signs logs in the residences of patients and took pictures of the logs with a personal phone when the logs were filled with multiple visits. An agency phone was available for this purpose, but the acting Administrator did not want the absent Administrator to know this was occurring to facilitate bulk entries of skilled visits at later dates. Patient #8 On 5/22/2024, the agency admitted Patient #8 with hypertension and chronic respiratory failure. On 5/22/2024, the agency certified Patient #8 from 5/22/2024 through 7/20/2024. On 5/22/2024, the plan of care revealed a physician ordered skilled nursing visits three times the first week, twice the second week and then weekly thereafter. On 7/20/2024, the agency recertified Patient #8 from 7/21/2024 through 9/18/2024. On 7/21/2024, the plan of care revealed a physician ordered skilled nursing visits twice the first week and then weekly thereafter. On 9/19/2024 at 1:30 PM, clinical record review revealed there was no documented evidence the agency documented any ordered skilled nursing visits from the start of care dated 5/22/2024 to the present 9/19/2024. The acting Administrator indicated the patient had been in the hospital since 8/1/2024. A discharge OASIS was submitted and accepted on 8/31/2024. The acting Administrator indicated knowing the patients when asked how visits were documented weeks and months after they were conducted. The acting Administrator did not keep a notebook or have a technique to record pertinent data from specific visits, yet each blank skilled nursing visit was authenticated, dated and timed corresponding to the original date and time when the visits were conducted. Patient #10 On 8/19/2024, the agency admitted Patient #10 with chronic obstructive pulmonary disease. In anticipation of a skilled nursing visit on 9/18/2024, the clinical record was reviewed with the following anomalies identified: The start of care OASIS assessment (8/19/2024) was incomplete and printed out at 4:59 PM on 9/17/2024. The plan of care requested for the home visit was incomplete. Start of care orders were not entered. No skilled nursing visits were documented. On 8/19/2024, the agency certified Patient #10 from 8/19/2024 through 10/17/2024. On 8/19/2024, the incomplete plan of care revealed a physician ordered skilled nursing visits twice the first week and then weekly thereafter. On 9/18/2024, Patient #10 was selected for a home visit with a skilled nurse. On 9/19/2024 at noon, the acting Administrator was observed completing the start of care OASIS assessment when it was discovered in a second record review. The acting Administrator completed the document and submitted it to CMS at 8:11 PM on 9/18/2024, after the day the home visit was completed. The start of care orders were now entered and the plan of care was now completed as well. The acting Administrator confirmed that the skilled nursing visits were now being entered during the survey and signed with the dates and times of when the visits were conducted weeks before. The newly entered skilled nursing visits lacked documented evidence of homebound status for 8/23/2024, 8/26/2024 and 9/13/2024. Patient #12 On 5/30/2024, the agency admitted Patient #12 with acute chronic obstructive pulmonary disease. The agency certified the patient from 5/30/2024 through 7/28/2024. On 5/30/2024, the plan of care revealed a physician ordered skilled nursing visits once the first week, twice the second week and then weekly thereafter. On 7/27/2024, the agency recertified Patient #12 with essential hypertension. The agency recertified the patient from 7/29/2024 through 9/26/2024. On 7/29/2024, the plan of care revealed a physician ordered weekly skilled nursing visits. The clinical record lacked documented evidence of any skilled nursing visits for either certification period. On 9/19/2024 at 1:30 PM, clinical record review revealed there was no documented evidence the agency documented any ordered skilled nursing visits or missed visits from the start of care to the present 9/19/2024. The acting Administrator indicated the patient had been in the hospital since 8/1/2024. The acting Administrator indicated knowing the patients when asked how visits were documented weeks and months after they were conducted. The acting Administrator did not keep a notebook or have a technique to record pertinent data from specific visits. The visit calendar lacked documented evidence skilled nursing visits were even plotted and scheduled to be conducted since the start of care. At a later point in the survey, the acting Administrator continued silently entering skilled nursing visits for 7/31/2024 and 8/7/2024. The acting Administrator admitted documenting these two skilled nursing visits, even though they were conducted in the previous months. The acting Administrator verbalized missed visits for 6/8/2024, 7/2/2024, 8/3/2024, 8/14/2024 and 8/21/2024, even though none of these visits were plotted and scheduled on the corresponding visit calendar. The clinical record lacked documented evidence a physician changed, discontinued or otherwise modified the visit frequency for skilled nursing visits in either certification period. The Clinical Records and Maintenance policy provided revealed clinical notes were written the day of service delivery and incorporated into the clinical record at least weekly.

Goals in the patient's plans of care CFR(s): 484.110(a)(3) Goals in the patient's plans of care and the patient's progress toward achieving them; This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure goals, orders and treatments were included in a plan of care in a timely manner for 2 of 12 patients (Patient #11 and #12). Findings include: Patient #11 On 8/7/2024, the agency admitted Patient #11 with generalized osteoarthritis. On 8/7/2024, the plan of care revealed a physician ordered skilled nursing visits twice the first week and then weekly thereafter. On 9/18/2024, the clinical record was reviewed in anticipation for a home visit scheduled for 9/19/2024. On 9/19/2024, the plan of care provided lacked documented evidence of a complete list of patient goals and orders for discipline and treatments. The original plan of care provided was 3 pages compared to the revised plan of care after the home visit with goals, orders and treatments added of 4 pages. The acting Administrator confirmed the plan of care was updated, but the goals, orders and treatments should have been included near the start of care of 8/7/2024. Patient #12 On 5/30/2024, the agency admitted Patient #12 with acute chronic obstructive pulmonary disease. The agency certified the patient from 5/30/2024 through 7/28/2024. On 5/30/2024, the plan of care revealed a physician ordered skilled nursing visits once the first week, twice the second week and then weekly thereafter. On 7/27/2024, the agency recertified Patient #12 with essential hypertension. The agency recertified the patient from 7/29/2024 through 9/26/2024. On 7/29/2024, the plan of care revealed a physician ordered weekly skilled nursing visits. On 9/19/2024, the plans of care provided for both certification periods lacked documented evidence of a complete list of patient goals and orders for discipline and treatments. The original plan of care provided was 3 pages compared to the 4 or more pages for other patients reviewed. The acting Administrator verbalized the goals, orders and treatments should have been included near the start of each certification period. The Clinical Records and Maintenance policy provided revealed clinical notes were written the day of service delivery and incorporated into the clinical record at least weekly.

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: Based on record review, interview and policy review, the agency failed to ensure it documented a discharge order and discharge summary within 2 days of discharge for 2 of 12 patients (Patient #6 and #12). Findings include: Patient #6 On 7/5/2024, the agency admitted Patient #6 with hypertension. On 7/5/2024, the agency certified Patient #6 from 7/5/2024 through 9/2/2024. On 7/5/2024, the plan of care revealed a physician ordered skilled nursing visits once the first week, twice the second week and weekly thereafter. On 9/19/2024 at 1:00 PM, the following anomalies were identified during clinical record review: The clinical record had a recertification period dated 9/3/2024 through 11/1/2024. The clinical record lacked a recertification assessment but had a plan of care for the recertification period with ordered skilled nursing visits. The visit calendar was blank, meaning no skilled nursing visits were scheduled, conducted or documented for September 2024. The last skilled nursing visit conducted and documented was dated 8/30/2024. On 9/19/2024, the acting Administrator stated the patient was discharged, despite no documented evidence in the clinical record. On 9/24/2024 upon recapping the issues identified, it was observed the acting Administrator had entered a discharge order dated 8/30/2024, which was not in the record on 9/19/2024. Evidence in the visit calendar now revealed a discharge on 8/30/2024. A discharge OASIS assessment was now entered but incomplete dated 8/30/2024. On 9/24/2024 in the morning, the acting Administrator confirmed the findings, indicating the information was added during the survey period. Patient #12 On 5/30/2024, the agency admitted Patient #12 with acute chronic obstructive pulmonary disease. The agency certified the patient from 5/30/2024 through 7/28/2024. On 5/30/2024, the plan of care revealed a physician ordered skilled nursing visits once the first week, twice the second week and then weekly thereafter. On 7/27/2024, the agency recertified Patient #12 with essential hypertension. The agency recertified the patient from 7/29/2024 through 9/26/2024. On 7/29/2024, the plan of care revealed a physician ordered weekly skilled nursing visits. The clinical record lacked documented evidence of any skilled nursing visits for either certification period. On 9/19/2024 at 1:30 PM, clinical record review revealed there was no documented evidence the agency documented any ordered skilled nursing visits or missed visits from the start of care to the present 9/19/2024. The acting Administrator indicated the patient had been in the hospital since 8/1/2024. The acting Administrator indicated knowing the patients when asked how visits were documented weeks and months after they were conducted. The acting Administrator did not keep a notebook or have a technique to record pertinent data from specific visits. The visit calendar lacked documented evidence skilled nursing visits were even plotted and scheduled to be conducted since the start of care. At a later point in the survey, the acting Administrator continued silently entering skilled nursing visits for 7/31/2024 and 8/7/2024. The acting Administrator was confronted and admitted documenting these two skilled nursing visits, even though they were conducted in the previous months. The acting Administrator verbalized missed visits for 6/8/2024, 7/2/2024, 8/3/2024, 8/14/2024 and 8/21/2024, even though none of these visits were plotted and scheduled on the corresponding visit calendar. The clinical record lacked documented evidence a physician changed, discontinued or otherwise modified the visit frequency for skilled nursing visits in either certification period. The acting Administrator entered a discharge order due to not being able to locate the patient and backdated the order to 8/28/2024. None of the above documentation was accompanied by any indication of a correction or late entry. There was no documented evidence of a discharge summary. The Confidentiality of Client Information policy revealed initials may be used on designated forms to indicate review, revisions, or correction of entry. The Clinical Records and Maintenance policy provided revealed clinical notes were written the day of service delivery and incorporated into the clinical record at least weekly.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure it appropriately authenticated, dated and timed its documentation for 5 of 12 patients (Patient #6, #7, #8, #10 and #12). Findings include: Patient #6 On 7/5/2024, the agency admitted Patient #6 with hypertension. On 7/5/2024, the agency certified Patient #6 from 7/5/2024 through 9/2/2024. On 7/5/2024, the plan of care revealed a physician ordered skilled nursing visits once the first week, twice the second week and weekly thereafter. On 9/19/2024 at 1:00 PM, the following anomalies were identified during clinical record review: The clinical record had a recertification period dated 9/3/2024 through 11/1/2024. The clinical record lacked a recertification assessment but had a plan of care for the recertification period with ordered skilled nursing visits. The visit calendar was blank, meaning no skilled nursing visits were scheduled, conducted or documented for September 2024. The last skilled nursing visit conducted and documented was dated 8/30/2024. On 9/19/2024, the acting Administrator stated the patient was discharged, despite no documented evidence in the clinical record. On 9/24/2024 upon recapping the issues identified, it was observed the acting Administrator had entered a discharge order dated 8/30/2024, which was not in the record on 9/19/2024. Evidence in the visit calendar now revealed a discharge on 8/30/2024. A discharge OASIS assessment was now entered but incomplete dated 8/30/2024. The September visit calendar and plan of care were no longer present in the clinical record. On 9/24/2024 in the morning, the acting Administrator confirmed the findings, indicating the information was added during the survey period. There was no documented evidence any of the above additions/changes to the clinical record were identified with a correction or late entry designation. Patient #7 On 7/25/2024, the agency admitted Patient #7 with paroxysmal atrial fibrillation. On 7/25/2024, the plan of care showed the agency conducted and documented weekly physical therapy visits. On 9/20/2024, record review identified a physical therapist had documented an incomplete physical therapy reassessment dated 8/24/2024. The acting Administrator was asked several times during the survey to facilitate an interview with the physical therapist. The acting Administrator indicated it was a discharge. The acting Administrator failed to secure the interview with the physical therapist. By 9/24/2024, the physical therapist had removed the reassessment and instead documented a physical therapy discharge dated 8/24/2024. The reassessment and discharge documents were indistinguishable from each other regarding the date and time of the original visit, which was 3:00 PM on 8/24/2024. There was no correction or late entry designation. On 9/24/2024, the acting Administrator indicated the therapist had entered the physical therapy discharge. The agency did not provide a policy regarding correcting clinical records or making late entries. On 7/25/2024, the plan of care revealed a physician ordered skilled nursing visits once the first week, twice the second week and then weekly thereafter. On 9/24/2024, a clinical record review revealed the entire certification period had all ordered skilled nursing visits plotted on the visit calendar, but all the visit notes were blank. The acting Administrator was observed trying to fill in the data from the visits during the survey. The Acting Administrator did not keep a notebook or some other technique of recording key data of visits aside from vital signs. The skilled nursing visit sheets were all electronically authenticated from dates/times of the actual visits with no data entered. The acting Administrator kept vital signs logs in the residences of patients and took pictures of the logs with a personal phone when the logs were filled with multiple visits. An agency phone was available for this purpose, but the acting Administrator did not want the absent Administrator to know this was occurring to facilitate bulk entries of skilled visits at later dates. Patient #8 On 5/22/2024, the agency admitted Patient #8 with hypertension and chronic respiratory failure. On 5/22/2024, the agency certified Patient #8 from 5/22/2024 through 7/20/2024. On 5/22/2024, the plan of care revealed a physician ordered skilled nursing visits three times the first week, twice the second week and then weekly thereafter. On 7/20/2024, the agency recertified Patient #8 from 7/21/2024 through 9/18/2024. On 7/21/2024, the plan of care revealed a physician ordered skilled nursing visits twice the first week and then weekly thereafter. On 9/19/2024 at 1:30 PM, clinical record review revealed there was no documented evidence the agency documented any ordered skilled nursing visits from the start of care dated 5/22/2024 to the present 9/19/2024. The acting Administrator indicated the patient had been in the hospital since 8/1/2024. A discharge OASIS was submitted and accepted on 8/31/2024. The acting Administrator indicated knowing the patients when asked how visits were documented weeks and months after they were conducted. The acting Administrator did not keep a notebook or have a technique to record pertinent data from specific visits, yet each blank skilled nursing visit was authenticated, dated and timed corresponding to the original date and time when the visits were conducted. Patient #10 On 8/19/2024, the agency admitted Patient #10 with chronic obstructive pulmonary disease. In anticipation of a skilled nursing visit on 9/18/2024, the clinical record was reviewed with the following anomalies identified: The start of care OASIS assessment (8/19/2024) was incomplete and printed out at 4:59 PM on 9/17/2024. The plan of care requested for the home visit was incomplete. Start of care orders were not entered. No skilled nursing visits were documented. On 8/19/2024, the agency certified Patient #10 from 8/19/2024 through 10/17/2024. On 8/19/2024, the incomplete plan of care revealed a physician ordered skilled nursing visits twice the first week and then weekly thereafter. On 9/18/2024, Patient #10 was selected for a home visit with a skilled nurse. On 9/19/2024 at noon, the acting Administrator was observed completing the start of care OASIS assessment when it was observed in a second record review. The acting Administrator completed the document and submitted it to CMS at 8:11 PM on 9/18/2024, after the day the home visit was completed. The start of care orders were now entered and the plan of care was now completed as well. The acting Administrator confirmed that the skilled nursing visits were now being entered during the survey and signed with the dates and times of when the visits were conducted weeks before. The newly entered skilled nursing visits lacked documented evidence of homebound status for 8/23/2024, 8/26/2024 and 9/13/2024. Patient #12 On 5/30/2024, the agency admitted Patient #12 with acute chronic obstructive pulmonary disease. The agency certified the patient from 5/30/2024 through 7/28/2024. On 5/30/2024, the plan of care revealed a physician ordered skilled nursing visits once the first week, twice the second week and then weekly thereafter. On 7/27/2024, the agency recertified Patient #12 with essential hypertension. The agency recertified the patient from 7/29/2024 through 9/26/2024. On 7/29/2024, the plan of care revealed a physician ordered weekly skilled nursing visits. The clinical record lacked documented evidence of any skilled nursing visits for either certification period. On 9/19/2024 at 1:30 PM, clinical record review revealed there was no documented evidence the agency documented any ordered skilled nursing visits or missed visits from the start of care to the present 9/19/2024. The acting Administrator indicated the patient had been in the hospital since 8/1/2024. The acting Administrator indicated knowing the patients when asked how visits were documented weeks and months after they were conducted. The acting Administrator did not keep a notebook or have a technique to record pertinent data from specific visits. The visit calendar lacked documented evidence skilled nursing visits were even plotted and scheduled to be conducted since the start of care. At a later point in the survey, the acting Administrator continued attempting to circumvent the surveyor by silently entering skilled nursing visits for 7/31/2024 and 8/7/2024. The acting Administrator admitted documenting these two skilled nursing visits, even though they were conducted in the previous months. The acting Administrator verbalized missed visits for 6/8/2024, 7/2/2024, 8/3/2024, 8/14/2024 and 8/21/2024, even though none of these visits were plotted and scheduled on the corresponding visit calendar. The clinical record lacked documented evidence a physician changed, discontinued or otherwise modified the visit frequency for skilled nursing visits in either certification period. The acting Administrator entered a discharge order due to not being able to locate the patient and backdated the order to 8/28/2024. None of the above documentation was accompanied by any indication of a correction or late entry. The Confidentiality of Client Information policy revealed initials may be used on designated forms to indicate review, revisions, or correction of entry. The Clinical Records and Maintenance policy provided revealed clinical notes were written the day of service delivery and incorporated into the clinical record at least weekly.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure it had policies and procedures to ensure the security of clinical records and the privacy of information contained within such records to prevent loss or unauthorized use in the patient's home, in transit, in the office setting, or any other location for all patients (Patient #10 as an example). Findings include: Patient #10 On 8/19/2024, the agency admitted Patient #10 with chronic obstructive pulmonary disease. On 8/19/2024, the agency certified Patient #10 from 8/19/2024 through 10/17/2024. On 8/19/2024, the incomplete plan of care revealed a physician ordered skilled nursing visits twice the first week and then weekly thereafter. On 9/18/2024, Patient #10 was selected for a home visit with a skilled nurse. The acting Administrator, a registered nurse, kept vital signs logs in the residences of patients and took pictures of the logs with a personal phone when the logs were filled with multiple visits. This was witnessed on one of the home visits. An agency phone was available for this purpose, but the acting Administrator did not want the absent Administrator to know this was occurring to facilitate bulk electronic entries of skilled visits at later dates. The agency's Confidentiality of Client Information policy failed to include a directive advising whether or not the practice of photographing vital sign logs in patient residences was an acceptable practice, whether or not an agency device versus a personal device should be used for the purpose and what security measures would be in place to protect the information on the agency/personal device, if acceptable for this practice.