Every finding on record at Adoration Home Health and Hospice Care East Tennessee

An Emergency Preparedness survey was conducted from 4/19/2022 to 4/21/2022 at Adoration Home Health and Hospice. Deficiencies were cited under CFR Part 484.22 Condition of Participation for Home Health Agencies.

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), §485.625(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, 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 policy review and emergency preparedness documentation, the facility failed to analyze the response to a disaster exercise drill dated 12/29/21. The findings include: Review of the Emergency Operations Plan (not dated) revealed "...An after action review (AAR) will be held within 2 weeks after the disaster or exercise...A written report will be completed within 1 month and will include a plan for corrective action...Further exercises will be utilized to evaluate the effectiveness of improvements that were made in response to critiques of the previous exercise..." Review of Emergency Preparedness Exercise and Testing dated 12/29/2021 revealed the scenario was severe potential weather. Further review revealed response participants only included internal staff and managers. No analysis was completed in the 2 week time frame. Continued review revealed a written report was not completed within 1 month to include a possible plan for corrective action. Interview with the alternate administrator on 4/21/2022 at 10:00 AM confirmed the analysis had not been completed.

A Recertification survey was conducted on 4/19/2022 to 4/21/2022 at Adoration Home Health and Hospice. Deficiencies were cited under CFR Part 484, Requirements for Homecare Organizations Providing Home Health Care.

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: This Condition is not met as evidenced by: Based on policy review, observation, medical record review and interview, it was determined that the home health agency (HHA) failed to complete an initial comprehensive assessment within 48 hours (G514). The HHA failed to provide goals based on patient's preferences (G530). The HHA failed to complete a review of all current medications (G536). The cumulative effect of these systemic practices resulted in the agency's inability to ensure that the patients' needs would be met.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on medical record review and interview, the agency failed to admit 1 patient (#2) within the 48 hours of the referral date out of 17 patients reviewed. The findings include: Medical record review revealed Patient #2 was admitted to the agency on 4/6/2022 with diagnoses including Alzheimer's Disease and Dementia. Medical record review of the physician's referral dated 3/31/2022 revealed an order for home health care to provide physical and occupation therapy. Medical record review of a physical therapy note dated 4/6/2022 revealed the initial evaluation was not completed until 4/6/2022 (6 days after referral). Interview with the administrator on 4/21/2022 at 10:15 AM confirmed the initial admission assessment by the physical therapist was not completed within 48 hours of the referral date.

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on medical record review and interview, the agency failed to include a pain goal for 1 patient (#10) of 17 patients reviewed. The findings include: Medical record review revealed Patient #10 was admitted to the agency on 3/7/2022 with diagnoses including Transient Cerebral Ischemic Attack and Pain. Medical record review of the Home Health Certification and Plan of Care (485) dated 3/7/2022 to 5/5/2022 revealed the patient's identified Personal Goal for care was "to feel better". Medical record review of a physical therapy assistant's note dated 3/17/2022 revealed "...Patient states back pain is terrible today. States feeling real bad...Increased by standing and ambulation. Unable to rate on 0/10 scale, states its terrible today...Interferes with: All mobility...Patient with increased back pain today, limiting addition of new ex (exercise) or progressing gt (gait) distance..." Medical record review of a physical therapy assistant's note dated 3/24/2022 revealed "...Patient states back pain is terrible today...Increased by: Standing and ambulation. Unable to rate on 0/10 scale, states its terrible today...Interferes with: All mobility..." Continued review of the 485 dated 3/7/2022 to 5/5/2022 revealed no goals related to pain were identified or added to the patient's 485. Interview with the administrator on 4/21/2022 at 11:00 AM confirmed a goal related to pain control was not identified on the 485.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, observation and interview, the agency failed to reconcile medications for 1 patient (#1) of 7 patients observed and reviewed. The findings include: Review of the Medication Reconciliation policy (not dated) revealed "...2. The medication list/profile will be updated with each new or changed medication..." Observation of Patient #1 on 4/19/2022 at 3:15 PM revealed the patient had been ordered the medication Vitamin D3 2000 unit tablets every day on 3/31/2022.. Review of the medications at the Assisted Living facility revealed on 3/31/2022 the Vitamin D was ordered by the physician. Review of the skilled nurse's notes from 4/5/2022 to 4/16/2022 revealed patient had been seen by the skilled nurse a total of 6 times and no documentation the medication was found. Review of the Medication Review Report dated 3/8/2022 for Patient #1 revealed no documentation the Vitamin D3 had been added to the medication profile. Interview with the administrator on 4/21/2022 at 9:10 AM confirmed the agency failed to reconcile medications for medication changes.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: This Condition is not met as evidenced by: Based on medical record review and interview, it was determined that the home health agency (HHA) failed to include patient preference goals (G574). The HHA failed to ensure all orders were recorded in the plan of care (G576). The HHA failed to alert the physician of patient changes (G590). The HHA failed to alert the physician of a patient's discharge in a timely manner (G598). The cumulative effect of these systemic practices resulted in the agency's inability to ensure that the patients' nursing needs would be met.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on medical record review and interview, the agency failed to add measurable goals pertaining to pain for 1 patient (#10) of 17 patients reviewed. The findings include: Medical record review revealed Patient #10 was admitted to the agency on 3/7/2022 with diagnoses including Transient Cerebral Ischemic Attack and Pain. Medical record review of the Home Health Certification and Plan of Care (485) dated 3/7/2022 to 5/5/2022 revealed the patient's identified Personal Goal for care was "to feel better". Medical record review of a physical therapy assistant's note dated 3/17/2022 revealed "...Patient states back pain is terrible today. States feeling real bad...Increased by standing and ambulation. Unable to rate on 0/10 scale, states its terrible today...Interferes with: All mobility...Patient with increased back pain today, limiting addition of new ex (exercise) or progressing gt (gait) distance..." Medical record review of a physical therapy assistant's note dated 3/24/2022 revealed "...Patient states back pain is terrible today...Increased by: Standing and ambulation. Unable to rate on 0/10 scale, states its terrible today...Interferes with: All mobility..." Continued review of the 485 dated 3/7/2022 to 5/5/2022 revealed no measurable goals related to pain were identified or added to the patient's 485. Interview with the administrator on 4/21/2022 at 11:00 AM confirmed the agency failed to add measurable goals related to pain to the patient's 485.

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: Based on medical record review and interview, the agency failed to provide physical therapy as ordered by the physician for 1 patient (#1); failed to provide an occupational therapy evaluation as ordered on the referral for 1 patient (#2); and failed to assess blood sugar levels for 1 patient (#7) of 17 patients reviewed. The findings include: Medical record review revealed Patient #1 was admitted to the agency on 3/8/2022 with diagnoses including Osteoarthritis and Pain in Right and Left Shoulder. Medical record review of the Home Health Certification and Plan of Care (485) revealed a physician's order for physical therapy evaluation and treatment to begin week of 3/20/2022. Medical record review of the physical therapy note dated 3/30/2022 revealed the evaluation was not completed the week of 3/20/2022 and was delayed 1 week to the week of 3/27/2022. No documentation the physician was notified of the delay of the physical therapy evaluation. Interview with the administrator on 4/21/2022 at 10:00 AM confirmed the evaluation was not completed as ordered by the physician and the physician was not notified of the delay. Patient #2 was admitted to the agency on 4/6/2022 with diagnoses including Alzheimer's Disease and Muscle Weakness. Medical record review of the physician's referral dated 3/31/2022 revealed an order for physical therapy and occupational therapy to evaluate and treat for "leaning forward" Ataxia, Unsteady Gait and increased assistance with activities of daily living. Medical record review of the 485 dated 4/6/2022 to 6/4/2022 revealed an order for Physical Therapy. Further review revealed occupational therapy was not ordered as requested by physician's referral. Interview with the administrator on 4/21/2022 at 10:15 AM revealed the physician at times would order both physical therapy and occupational therapy. Further interview revealed at times the physician would only need the physical therapy. Continue interview confirmed the agency did not contact the physician for clarification for the need of occupational therapy. Medical record review revealed Patient #7 was admitted to the agency on 4/11/2022 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer and Acute Osteomyelitis. Medical record review of the patient's 485 dated 4/11/2022 to 6/9/2022 revealed an order for "SN (skilled nurse) to assess blood sugar via finger stick every visit prior to insulin administration..." Further review revealed the SN was to report to the physician blood sugars greater than 400 and less than 50. Medical record review of the SN notes dated 4/13/2022 and 4/15/2022 revealed the SN did not assess the patient's blood sugars. Interview with the administrator on 4/21/2022 at 10:30 AM confirmed the SN did not assess the patient's blood sugars on 4/13/2022 and 4/15/2022.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, medical record review and interview, the agency failed to alert the physician regarding the delay of a physical therapy evaluation for 1 patient (#1); failed to clarify orders on the referral with the physician for 1 patient (#2); and failed to notify the physician of increased pain for 1 patient (#10). The findings include: Medical record review revealed Patient #1 was admitted to the agency on 3/8/2022 with diagnoses including Osteoarthritis and Pain in Right and Left Shoulder. Medical record review of the Home Health Certification and Plan of Care (485) revealed a physician's order for physical therapy evaluation and treatment to begin week of 3/20/2022. Medical record review of the physical therapy note dated 3/30/2022 revealed the evaluation was not completed the week of 3/20/2022 and was delayed 1 week to the week of 3/27/2022. No documentation the physician was notified of the delay of the physical therapy evaluation. Interview with the administrator on 4/21/2022 at 10:00 AM confirmed the physician was not alerted to the change of date for the physical therapy evaluation. Patient #2 was admitted to the agency on 4/6/2022 with diagnoses including Alzheimer's Disease and Muscle Weakness. Medical record review of the physician's referral dated 3/31/2022 revealed an order for physical therapy and occupational therapy to evaluate and treat for "leaning forward" Ataxia, Unsteady Gait and increased assistance with activities of daily living. Medical record review of the 485 dated 4/6/2022 to 6/4/2022 revealed no order for occupational therapy evaluation. Interview with the administrator on 4/21/2022 at 10:15 AM confirmed an occupational therapy evaluation was not completed and the physician was not alerted to the change. Medical record review revealed Patient #10 was admitted to the agency on 3/7/2022 with diagnoses Transient Cerebral Ischemic Attack and Pain. Review of the agency's policy "Pain Assessment and Reassessment" revealed "...When a patient's pain is not relieved, the nurse or therapist will intervene appropriately...Notification of patient's physician..." Medical record review of a physical therapy assistant's note dated 3/17/2022 revealed "...Patient states back pain is terrible today. States feeling real bad...Increased by standing and ambulation. Unable to rate on 0/10 scale, states its terrible today...Interferes with: All mobility...Patient with increased back pain today, limiting addition of new ex (exercise) or progressing gt (gait) distance..." Further review revealed no documentation the physician was alerted to the patient's increased pain which interfered with the patient's mobility. Medical record review of a physical therapy assistant's note dated 3/24/2022 revealed "...Patient states back pain is terrible today...Increased by: Standing and ambulation. Unable to rate on 0/10 scale, states its terrible today...Interferes with: All mobility..." Further review revealed no documentation the physician was alerted to the patient's increased pain which interfered with the patient's mobility. Interview with the administrator on 4/21/2022 at 11:00 AM confirmed the physician was not alerted to the patient's increased pain levels on 3/17/2022 and 3/24/2022.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's 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). This ELEMENT is not met as evidenced by: Based on the agency's discharge policy, medical record review and interview, the agency failed to inform the physician in a timely manner of a discharge for 1 patient (#2) of 6 patients who were discharged. The findings include: Review of the agency's discharge policy (not dated) revealed "...Physician...will be informed and knowledgeable of discharge..." Medical record review revealed Patient #2 was admitted to the agency on 3/3/2022 with diagnoses including Alzheimer's Disease and Dementia. Medical record review of the Home Health Care Certification and Plan of Care dated 3/3/2022 to 5/1/2022 revealed the physician's order for physical therapy at 1 time a week for 1 week, 2 times a week for 3 weeks and 1 time a week for 1 week. Medical record review of the physical therapy discharge note and summary dated 3/8/2022 revealed the "...patient was discharged due to insurance change with home health to readmit under new insurance...told (insurance) would be active again April 1st..." No documentation the physician was notified of the patient's discharge from the agency. Medical record review of communication notes revealed the physician was notified of the patient's discharge due to insurance issues on 4/13/2022 (Patient was discharged on 3/8/2022). Interview with the administrator on 4/21/2022 at 10:15 AM confirmed the physician was not notified of the patient's discharge in a timely manner.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, observation on 4/19/2022 at 2:00 PM and interview, the agency failed to maintain infection control for 1 patient (#2) of 7 patients reviewed. The findings include: Review of Exposure Control Plan OSHA Regulations (not dated) revealed "...Nursing Bag Technique...#2: On entering the home place the bag on a clean surface...Place items on one of the paper towels, close the bag and give patient care..." Observation of Patient #2 on 4/19/2022 at 2:00 PM revealed the Physical Therapist Assistant #1 (PTA) placed nursing bag on floor and opened the bag. Further observations revealed he retrieved items needed for visit and did not close bag. Continued observation revealed the PTA placed the agency's computer on top of a table with no barrier. Interview the PTA #1 on 4/19/2022 at 2:20 PM confirmed he had placed his nursing bag on the floor. Interview with the administrator on 4/21/2022 at 8:15 AM confirmed agency failed to maintain infection control by placing bag on the floor and not closing the bag when not in use. Further interview confirmed computer should not have been placed on the table without a barrier.

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: Based on policy review, staff vaccination status and interview, the agency failed to have 100% staff vaccinations to include medical and non-medical exemptions and failed to have a process to accurately track staff vaccination status for medical and non-medical exemption status. The findings include: Review of COVID-19 Vaccine Immunization Requirements for Staff revised 1/28/22 revealed the following exemptions permitted include "...Recognized medical conditions for which vaccines are contraindicated. Documentation must include a statement by the authenticating practitioner recommending the staff member be exempted and must be signed by the licensed practitioner. Documentation must contain all information specifying why the COVID-19 vaccines are clinically contraindicated for the staff member..." Continued review revealed "...The documentation of all vaccinations will be maintained and available to serve as proof of compliance and presented on demand to regulatory bodies. All vaccination records will be retained in accordance with the company's record retention policy..." Review of staff list revealed 190 staff members who have contact with patients. Review of staff list provided to the surveyor of non-vaccinated staff included 36 staff members. Upon review by the agency it was determined the staff vaccination tracker was incorrect and had not been updated. Review of final list provided to the surveyor revealed a total of 190 staff. Further review revealed 131 had been fully vaccinated. Continued review revealed 3 staff members had medical exemptions and 48 staff members had non-medical exemptions. Further review revealed 8 staff members were in the process of orientation and had no contact with patients. Staff vaccination percentage was 99%. Review of 1 non-medical exemption revealed LPN #1 was hired on 3/17/2022. She received her non-medical exemption on 4/19/2022. Continued review revealed she saw patients before she received her non-medical exemption. Review of LPN #2's medical exemption revealed she did not have a history of previous allergic reactions to indicate an immediate hypersensitivity reaction to a component of the vaccine. Further review revealed she did not have a physical condition or medical circumstances which would indicate the immunization was not safe or advisable for her. Continued review revealed she had a history of Generalized Anxiety Disorder and Panic Attacks. Interview with the administrator on 4/21/2022 at 1:30 PM confirmed LPN #1 saw a patient before the non-medical exemption was granted and LPN #2 did not have a recognized condition to receive the medical exemption. Further interview confirmed the staff vaccination tracker had not been updated before surveyors entered the agency.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on policy review, medical record review and interview, the agency failed to provide instructions on pain management for 1 patient (#10) of 17 patients reviewed. The findings include: Medical record review revealed Patient #10 was admitted to the agency on 3/7/2022 with diagnoses including Transient Cerebral Ischemic Attack and Pain. Review of the agency's Pain Assessment and Reassessment policy (not dated) revealed "...When a patient's pain is not relieved, the nurse or therapist will intervene appropriately...Patient education regarding alternative pain relief measures..." Medical record review of the physical therapy assistant's note dated 3/17/2022 revealed "...Patient states back pain is terrible today. States feeling real bad...Increased by: Standing and ambulation. Unable to rate 0/10 scale, states it's terrible today...Interferes with: All mobility..." Further review revealed no documentation the patient or caregivers were instructed on alternative pain relief measures. Interview with the administrator on 4/21/2022 at 11:00 AM confirmed no documentation the patient was educated on alternative pain relief measures per the agency's policy.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on medical record review and interview, the agency failed to document the site of an intramuscular injection for 1 patient (#1) of 1 patient reviewed for injections. The findings include: Medical record review revealed Patient #1 was admitted to the agency on 3/8/2022 with diagnoses of Type 2 Diabetes with Peripheral Angiopathy and Urinary Infections. Medical record review of a physician's order dated 4/12/2022 revealed an order for the skilled nurse to administer Rocephin (antibiotic) 1 gram intramuscular every day for 5 days. Medical record review of a skilled nursing visit dated 4/16/2022 revealed "...SN (skilled nurse) to admin (administer) IM (intramuscular) 1-gram QD (everyday) x (times) 5 days. Effective 4/12/2022 (watch closely for S/SX (signs/symptoms) allergic reaction due to patient having allergy to PCN (penicillin)...Performed on: Patient..." Further interview revealed no documentation the site of the intramuscular injection. Interview with administrator on 4/21/2022 at 10:00 AM confirmed the injection site was not documented.