Every finding on record at Accord Home Health Services, Inc

Recertification survey completed. Standard level deficiencies cited. Abbreviations: PT = Physical Therapist SN = Skilled Nursing POC = Plan of care COVID - 19 = Corona Virus Disease 2019

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), §485.625(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: A. Based on review of Agency's Emergency Preparedness Binder and Staff Interview, it was determined the Agency failed to ensure the Emergency Preparedness Plan was based on a community risk assessment, utilizing an all-hazards approach. Findings include: 1. The Agency's Emergency Preparedness Binder was reviewed on 12/15/2022 at 1:15 PM. The plan lacked documentation that a facility based and/or a community based risk assessment was completed after 2021. 2. During an interview with the Administrator on 12/15/2022 at 1:15 PM, the Administrator confirmed the above findings.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: PT = Physical Therapist SN = Skilled Nursing POC = Plan of care COVID - 19 = Corona Virus Disease 2019

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: A. Based on home visit interview, clinical records review and staff interviews it was determined that the Agency failed to ensure staff followed services in conformance with the physician orders. This was found in 3 of 7 clinical records reviewed (Pts # 1,7 and 2). 3. Pt # 2 SOC 08/08/2022 Diagnosis: Unspecified focal TBI with LOC unspecified duration. The clinical record was reviewed on 12/14/2022 at 1:30 PM. The clinical record contained a POC for certification period of 10/07/22 – 12/05/22 that required SN frequency of 1 visit every 2 weeks. The clinical record contained SN visits dated 10/20, 11/9, 11/23 and 12/5/22. The record lacked SN visit for week of 10/31/22 to 11/05/22. No modification orders found in the clinical record. 4. On 12/15/2022, from 11:00 AM to 12:30 PM, interviews were conducted with the Administrator and Director of Nursing, both confirmed the above findings. Findings include: 1. Pt #1 SOC 09/02/2022. Diagnosis: Hemiplegia following Cerebral Infarct. A SN home visit was conducted to Pt #1 residence on 12/14/22 at 2:30 PM. During the home interview Pt#1 and patient caregiver stated PT is no longer providing care after 11/28/22. Pt #1 clinical record was reviewed on 12/14/22 at 1:00 PM and on 12/15/22 at 11:30 AM. The clinical record contained a POC for certification period 11/01/22 to 12/30/22 that required PT frequency of 1 time a week for 9 weeks. The clinical record contained PT weekly visits on 11/9, 11/14, 11/23 and 11/28/22 (week 5). No visits documented after 11/28/22 (week 5). No modification orders were found in the clinical record. 2. Pt #7 SOC 03/26/22. Diagnosis: Heart Failure Unspecified. The clinical record was reviewed on 12/14/22 at 1:30 PM. The clinical record contained a POC for certification period beginning 03/26/22 to 05/24/22 that required SN frequency of 1 time a week for 9 weeks and PT frequency of 1 time a week for 7 weeks. The clinical record lacked SN visits for weeks 2, 4, 5, 6, 7 and 9 of certification period. Pt #7 clinical record also lacked PT visits for weeks 6, 7, 8 and 9 of certification period. No modification orders were found in the clinical record.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: A. Based on the Agency’s Covid -19 policy review and staff interview, it was determined the Agency failed to develop a process by which staff may request an exemption for COVID-19 vaccination. Findings include: 1. The Agency’s policy titled “Emergency Preparedness Plan: COVID-19" was reviewed on 12/15/22 at 11:30 AM. The policy lacked a process by which staff may request an exemption for COVID-19 vaccination. 2. During an interview with the Administrator and Director of Nursing on 12/15/22 at 12:30PM, finding of the Agency Covid -19 policy not containing a process staff may request an exemption for COVID-19 vaccination was confirmed.