Every finding on record at Admire Home Healthcare Agency, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 06/21/24. Standard level deficiencies cited.

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 a review of the Agency’s Emergency Preparedness Plan and Staff interview, it was determined the Agency failed to ensure the Plan was established based on a risk assessment using an all hazards approach. Findings include: 1. The Emergency Preparedness Plan was reviewed on 06/20/24. The Plan contained documentation that a Hazard Vulnerability Assessment was conducted on 07/02/21. The Plan lacked documentation that a facility-based and/or community-based risk assessment was completed for 2022 and 2023. 2. During an interview with the Administrator, Director of Nursing and Alternate Director of Nursing on 06/20/24 at 10:00 AM, the Administrator confirmed that the Agency lacked risk assessment after 2021.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and Staff interview, it was determined the Agency failed to participate in a full-scale community or facility-based exercise or activate the Agency’s Emergency Preparedness Plan as required. Findings include: 1. The Emergency Preparedness Plan, last updated on 07/17/23, was reviewed on 06/20/24. The Plan contained documentation that the Agency conducted table-top exercises in 2022 and 2023. The Plan lacked documentation that the Agency participated in a full-scale community or facility-based exercise or had an actual activation of the Emergency Preparedness Plan as required. 2. During an interview with the Administrator, Director of Nursing and Alternate Director of Nursing on 06/20/24 at 10:00 AM, the Administrator confirmed that the Agency did not participate in a full-scale functional exercise nor activate the Emergency Preparedness Plan in 2022 and 2023.

A recertification survey conducted on 06/21/24. Standard level deficiencies cited. Abbreviations: w/ =with hr = hour Q = every # = number lbs. = pounds AM = morning > = greater than mg = milligrams SN = Skilled Nurse BS = Blood sugar f/u = follow-up FBS = Fasting Blood Sugar RBS = Random Blood Sugar POC = Plan of care SOC = Start of care PsOC = Plans of Care ST = Speech Therapy PT = Physical Therapy OT = Occupational Therapy SOB = Shortness of breath mg/dl = milligrams per deciliter MD = Medical Doctor RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients MSW = Medical Social Worker SNF = Skilled Nursing Facility APS = Adult Protective Services LSW = Licensed Social Worker

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on clinical record review and Staff interview, it was determined in 7 of 10 (Pts. #1, 7, 8, 2, 4, 3 and 6) clinical records reviewed, the Agency failed to inform the Pt. in advance of treatments, regarding the disciplines, services and/or frequency of visits. 6. Pt. #3 was admitted to the Home Health Services on 05/06/24 with the Diagnosis of: Acute Recurrent Sialoadenitis (Left Recurrent Supprurative Parotitis). The clinical record was reviewed on 06/18/24. The record contained the Agency's "Admission Consent" form completed by the SN and dated 05/06/24. The form included a section titled, "Consent for Treament" that required the SN to indicate the services to be provided, and the frequency of visits. This section was left blank. 7. Pt. #6 was admitted to Home Health Services on 02/24/24 with the Diagnoses of: Hypertensive Heart Disease with Heart Failure and Type 2 Diabetes Mellitus Without Complicatrions. The clinical record was reviewed on 6/20/24. The record contained the Agency's "Admission Consent" form completed by the SN and dated 02/24/24. The form included a section titled, "Consent for Treament" that required the SN to indicate the services to be provided, and the frequency of visits. This section was left blank. 8. During interviews with the Administrator, Director of Nursing and the Alternate Director of Nursing on 6/18/24 at 1:30 PM, 6/20/24 at 10:50 AM and 10:52 AM, all confirmed staff failed to indicate in writing the services to be provided, and visit frequencies of those services. 4. Pt. #2 was admitted to Home Health Services on 02/01/24 with Diagnosis of: Bilateral Primary Osteoarthritis. The clinical record was reviewed on 06/02/24. The clinical record contained an admission consent dated 02/01/24 that lacked the discipline to provide service and the proposed frequency for each discipline. 5. Pt. # 4 was admitted to Home Health Services on 01/07/24 with Diagnosis of: Hemiplegia following Cerebral Infarction Affecting Left Non-Dominant Side. The clinical record contained an admission consent dated 01/07/24 that lacked the discipline/disciplines to provide service and the proposed frequency for each discipline. Findings include: 1. Pt. #1 was admitted to the Home Health Services on 04/15/24 with the Diagnoses of: Pressure Ulcer of Sacral Region Stage 4 and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 06/18/24. The clinical record contained an admission consent dated 04/15/24 that lacked the frequency of the SN, PT and ST services. 2. Pt. #7 was admitted to the Home Health Services on 05/10/24 with the Diagnosis of: Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed 06/18/24. The clinical record contained an admission consent dated 05/10/24 that lacked the frequency of the SN services. 3. Pt. #8 was admitted to the Home Health Services on 12/06/23 with the Diagnosis of: Pressure Ulcer Left Heel Stage 2. The clinical record was reviewed 06/18/24. The clinical record contained an admission consent dated 12/06/23 that lacked the frequency of the SN services.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on the clinical record review and Staff interview, it was determined in 4 of 10 (Pts. #1, 8, 9 and 6) clinical records reviewed, the POC was not followed as ordered by the Physician. 4 Pt. #6 was admitted to Home Health Services on 02/24/24 with the Diagnoses of: Hypertensive Heart Disease with Heart Failure and Type 2 Diabetes Mellitus Without Complications. The clinical record was reviewed on 06/20/24. The record contained the POC effective 04/24/24 that required: "SN to check BS Q visit, notify MD if FBS > 200 mg/dl or 250 mg/dl or Findings include: 1. Pt. #1 was admitted to the Home Health Services on 04/15/24 with the Diagnoses of: Pressure Ulcer of Sacral Region Stage 4 and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. The clinical record was reviewed on 06/18/24. The clinical record contained a POC dated 04/15/24, that required SN to assess the patient’s blood glucose every week and notify the Physician of results greater than 200 mg or less than 60 mg. The SN failed to include the blood glucose assessment on 05/06/24 (week #4). 2. Pt. #8 was admitted to the Home Health Services on 12/06/23 with the Diagnosis of: Pressure Ulcer Left Heel Stage 2. The clinical record was reviewed on 06/18/24. The clinical record contained a recertification POC dated 04/04/24, that required SN to assess the patient’s weight every week and notify the Physician of weight loss or gain greater than 5 lbs. a week. The SN visit note 04/04/24 included a weight of 223 lbs. and on 04/11/24 a weight of 217 lbs. The SN failed to notify the Physician of the 6 lbs. weight loss. 3. Pt. #9 was admitted to the Home Health Services on 01/17/24 with the Diagnosis of: Staphylococcal Arthritis Left Wrist. The clinical record was reviewed on 06/18/24. The clinical record contained a POC dated 01/17/24 to require the SN to assess the patient 2 times a week for 1 week and 1 time a week for 8 weeks. The SN failed to visit the patient on 02/21/24 (week #6). The clinical record also contained a recertification POC dated 03/17/24, that required the OT to assess the patient’s vital signs. The OT failed to assess the vital signs on: 03/27/24, 04/03/24, 04/10/24, 04/17/24 and 04/24/24.

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on clinical record review, Agency policy and staff interview, it was determined that in 1 of 1 (Pt. #6) Pt. that received MSW service, the Agency failed to reassess the patient's social needs. . Findings include: 1. Pt. #6 was admitted to Home Health Services on 02/24/24 with the Diagnoses of: Hypertensive Heart Disease with Heart Failure and Type 2 Diabetes Mellitus Without Complications. The clinical record was reviewed on 06/20/24. The record contained the MSW evaluation assessment dated 3/18/24. The MSW evalution included: "...No family... Stated bank trying to take away his house... Had garbage scattered... soiled mattress in bedroom.... needs 24 hr caregiver... Not open to SNF... APS report filed for self neglect... Pt unable to care for himself at home. Called LSW saying he needed help getting food & going to bed... 1 visit w/ potential f/u visit..." The Physician Order dated 3/26/24 included Pt. was transferred to the hospital fo "SOB and wound infection". The record lacked documentation that the Agency notified the hospital regarding the patient's current living situation, and the APS referral made on 3/18/24. The PsOC dated 2/24/24 to 4/23/24, and effective 4/24/24 lacked a social component to address the above issues. The SN visit note date 3/23/24, resumption of care comprehensive assessment dated 4/16/24, SN visit note dated 4/20/24, recertification comprehensive assessment dated 4/23/24, and the weekly SN visit notes from 4/29/24 to 6/3/24, lacked a follow-up regarding Pt. #6's social issues, as indicated above. The record lacked documentation that the MSW conducted a follow-up visit. As of 6/20/24, the record lacked documentation the Agency followed-up on the APS investigation. 2. The Agency's policy titled, "Identifying and Reporting Abuse/Neglect or Exploitation of Clients" was reviewed on 6/20/24. The policy required: "...b. Document the assessment in the clinical record. When vulnerability is suspected or determined, it shall be addressed and highlighted on the care plan..." 3. During an interview with the Administrator, Director of Nursing, and the Alternate Director of Nursing on 6/20/24 at 10:52 AM, the Administrator stated the Agency should had contacted APS to follow-up on their investigation for Pt. #6. During the same interview, all confirmed the above findings.

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 a review of clinical records, Agency policy and Staff interview, it was determined that in 1 of 3 (Pt. #10), closed clinical records reviewed the Agency failed to ensure the Physician was sent a copy of the Transfer summary and Discharge summary. Findings include: 1. Pt. #10 was admitted to Home Health Services on 03/21/24 with diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease. The clinical record was reviewed on 06/20/24. A transfer summary dated 04/20/24, indicated Pt. #10 was transferred to inpatient hospital. The Transfer summary under “Notification of Transfer” section were marked and documented the Name of Facility, phone number, person receiving report, Name of Physician and phone number and "Will request if needed". The section "Date Report was received....Faxed/Mailed...Fax Number....Date..." were left blank.” The record lacked documentation that the transfer summary was sent to the health care facility where patient was receiving care. The discharge summary dated 05/02/24, indicated Pt. #10 was discharged from Agency. The record lacked documentation that the discharge summary was sent to the Physician. 2. The Agency policy titled: “Client Transfer” was reviewed on 06/20/24 and required: “….The original Transfer Summary form shall be sent to the new provider or facility….” The Agency policy titled: “Discharge Summary” was reviewed on 06/20/24 and required: “…. The supervising professional shall complete a discharge summary form at the date of discharge. A copy will be mailed to the physician….” 3. During an interview with the Administrator, Director of Nursing and Alternate Director of Nursing on 06/20/24 at 10:00 AM, the Administrator confirmed that the transfer and discharge summaries were not sent to the receiving facility and/or Physician.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to review and update its Emergency Preparedness Plan biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 6/9/21 at 11:45 AM. This plan was titled "Emergency Preparedness Manual." The Plan was last reviewed in 2018. 2. During an interview with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 06/9/21 at 1:30 PM, they confirmed the above findings.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to establish a policy and plan relative to the use of volunteers during an emergency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 6/9/21 at 11:45 AM. The Plan lacked a policy regarding the use of volunteers, and documentation relative to the use of volunteers. 2. During an interview with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 06/9/21 at 1:30 PM, they confirmed the Agency failed to establish a policy relative to the use of volunteers, and that the Agency's Emergency Preparedness Plan does not include the use of volunteers.

EP Testing Requirements CFR(s): 484.102(d)(2) *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, 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 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 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. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Program and Plan, and staff interviews, it was determined the Agency failed to ensure the Agency conducted Agency and community exercises and table top exercise to ensure the effectiveness of the Agency's Emergency Preparedness Plan. This has the potential to affect all patients receiving Home Health Care services. Findings Include: 1. The Agency's Emergency Preparedness Plan was reviewed on 6/9/21 at 11:45 AM. The Plan lacked documentation of community based and tabletop exercises for the years 2018, 2019 and 2020. 2. During an interview with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 06/9/21 at 1:30 PM, they confirmed the above findings.

. Recertification survey was conducted. Standard level deficiencies cited. Focused Infection Control Survey was conducted. Standard level deficiencies cited. Abbreviations: AM= Morning PM= Afternoon Pt./Pts. = Patient/Patients SOC= Start of Care SN = Skilled Nurse POC = Plan of Care

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: . A. Based on review of the Agency Home Care Surveillance Policy and staff interview, it was determined the Agency failed to maintain and implement a surveillance program to identify, prevent, control, monitor and track staff and Pts. This has the potential to affect all patients receiving services from the Agency. Findings: 1. The Agency's Home Care Surveillance was reviewed on 6/9/21 at 2:30 PM. The binder lacked any data related to infection control surveillance. The Agency also lacked any Infection Logs tracking staff and patient infections. The "Agency Home Care Surveillance" policy documents under: Policy: Agency will establish a continuous data monitoring and collecting system to detect infections or identify changes in infection trends. The three types od surveillance which may be used are: *Total surveillance - all infections identified in both clients and employees. *Targeted surveillance - specific infections, client populations, or procedures. *Outbreak surveillance - specific infections or infection clusters with a larger- than-expected cluster of infections within multiple clients at the same time. Purpose Surveillance activities will evaluate the effectiveness of existing control measures and identify opportunities for performance improvement. Special Instructions: 1.The agency will determine the types of surveillance activities it will perform. Reporting of Infections: The agency will establish internal and external reporting mechanisms for those infections identified during the surveillance activities. 3. "The agency will maintain records of all identified and reported infections. The reports will be used to compile reports identifying risks, trends, and rates ... " 4. "An infection control log will be maintained. The agency will identify follow-up actions taken as result of identified infections ..." 5. Targeted surveillance activities will be identified and implemented based on the results of the total surveillance program. 6. "Data related to identified infections will be reviewed and analyzed. Policies and procedures will be reviewed in light of infection surveillance reports and updated as needed to address areas of concern ..." 3. During an interview with the Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 06/9/21 at 1:30 PM, they stated surveillance procedures are not being followed and confirmed the above findings.

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: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure that documentation of forms was complete and accurate. This was found in 3 of 10 (Pts. #8, 9 and 10) clinical records reviewed. Findings include: 1. Pt. #8. SOC: 3/29/21. Principal Diagnosis: Lumbago with Sciatica. The clinical record was reviewed on 6/9/21 at 9:00 AM. The record contained a form titled: "Plan of Care Summary" which was signed by Pt. #8, lacked documentation of entries on the section, "Service/Treatment." 2. Pt. #9. SOC: 3/29/21. Principal Diagnosis: Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 6/9/21 at 10:00 AM. The record contained a form titled: "Consent and Agreement for Home Care Services" which was signed by Pt. #9, lacked documentation of entries on the sections, "Patient Agreement and Advance Directives." The record also contained a form "Plan of Care Summary" and lacked documentation of entries on the section, "Service/Treatment." The document in the record titled "Informed Consent Form For Influenza Virus Vaccine and Informed Consent For Pneumococcal Vaccine" which were also signed by Pt. #9, lacked documentation of entries in the section "Adverse Reactions and Contraindications." 3. Pt. #10. SOC 5/15/21. Principal Diagnosis: Tinea Unguium (Onychomycosis). The clinical record was reviewed on 6/8/21 at 10:00 AM. The record contained a form titled: "Consent and Agreement for Home Care Services" which was signed by Pt. #10, lacked documentation of entries on the section, "Advance Directives." 4. During an interview with the Administrator, Director of Nursing and Assistant Director of Nursing on 6/9/21 between 11:30 to 12:15 PM, the above findings were confirmed. The Administrative Staff stated staff should accurately complete the forms.