Every finding on record at Affinity Home Health Services, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 8/29/24. Standard level deficiencies cited.

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [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. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility 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 annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization 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 address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility 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. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to establish policies and procedures based on its risk assessment. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. On 8/26/24, the Emergency Preparedness Plan's "Hazard and Vulnerability Assessment Tool" (risk assessment) last updated on 8/1/23 was reviewed. The Assessment Tool identified threats or risks that included: "Earthquake, external flood, subsidence, epidemic, mass casualty incident (trauma), mass casualty incident (medical/infectious), terrorism, biological, civil disturbance, bomb threat". The Plan lacked policies and procedures to address these threats or risks. 2. During an interview with the Administrator and Director of Nursing on 8/26/24 at 2:50 PM, both confirmed the Agency failed to establish policies and procedures based on the Agency's Preparedness Emergency Plan's Assessment Tool/risk assessment.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Plan, staff in-services, and staff interview, it was determined in 2 of 4 (Employees #3 and 4) personnel files reviewed, the Agency failed to ensure staff received training pertaining to the Agency's Emergency Preparedness plan. This has the potential to affect staff that provide services, and Pts. receiving services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan, and staff in-services were reviewed on 8/26/24. The Agency lacked documentation the following employees received education pertaining to the Agency’s Emergency Preparedness Plan in 2021, 2022, 2023, and 2024 (as of 08/26/24): Employee #3. Date of hire 8/26/18. Employee #4. Date of hire 9/17/19. 2. During an interview with the Administrator and Director of Nursing/Agency Supervisor on 8/26/24 at 2:50 PM, the above findings were confirmed.

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 Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to conduct the required testing of its Emergency Preparedness Plan. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. On 8/26/24, the Agency's Emergency Preparedness Plan last updated 8/1/23 was reviewed. The Plan lacked documentation that the Agency conducted or participated in a full-scale exercise, facility-based exercise, or activated the Agency's Emergency Preparedness Plan in 2021, 2022, 2023 and 2024. 2. During an interview with the Administrator and Director of Nursing/Agency Supervisor on 8/26/24 at 2:50 PM, the Director of Nursing/Agency Supervisor stated the Agency conducted mock drills only in 2021, 2023 and 2024 (no exercises were documented in 2022). The Administrator and Director of Nursing/Agency Supervisor confirmed that the Agency failed to participate in a full-scale exercise, facility-based exercise, or activate the Agency's Emergency Preparedness Plan after March 2020.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: % = percent # = number AM = morning SN = Skilled Nurse SOC = Start of care PM = afternoon/evening Pt./ Pts. = Patient/Patients PT = Physical Therapy/Therapist OASIS = Outcome and Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report and staff interview, it was determined that the Agency failed to submit OASIS assessments within the required time frame for a 12 month period, resulting in a warning. Findings include: 1. The Error Summary report for 5/2023 to 4/2024 (12 months) was reviewed on 8/26/24. The report included a warning for 8 of 127 (6.30 %) assessments with Error # -3330 Record submitted late, more than 30 days after completing the assessment. 2. During an interview conducted with the Administrator and Director of Nursing/Agency Supervisor on 8/28/24 at 1:30 PM, the Administrator confirmed the above findings.

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 review of clinical records, observation during home visits, and staff interviews, it was determined that the Agency failed to ensure Pts. were informed in writing of the disciplines to provide care/service, and/ or the frequency of visits provided by each discipline. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 8/26/24 at 11:00 AM to 8/28/24 at 11:00 AM: Pt. #1. SOC 6/21/24. Pt. received SN services. Pt. #2. SOC 7/23/24. Pt. received SN and PT services. Pt. #3. SOC 6/20/24. Pt. received SN and Home Health Aide services. Pt. #4. SOC 1/23/24. Pt. received SN services. Pt. #5. SOC 7/22/24. PT. received SN services. Pt. #6. SOC 11/27/23. Pt. received SN, PT, and Home Health Aide services. Pt. #7. SOC 3/30/23. Pt. received SN services. . The records lacked documentation that the Pt. or legal guardian was notified in writing of the services to be provided and the frequency. 2. Home visits were conducted at the residence of Pts. #1, #2 and #3 on 8/27/24 and 8/28/24. During the home visits, the Pt’s. admission folder was observed and lacked documentation the Agency had provided Pt. or legal guardian information, regarding the disciplines and/or the frequency of visits. 3. During interview with the Administrator and Director of Nursing/ Agency Supervisor on 8/28/24 at 11:35 AM and 2:45 PM, it was confirmed the Agency failed to specify all disciplines and or the frequency of visits who provide services.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the Agency failed to assess the need for Influenza and Pneumococcal Pneumonia vaccines for 6 of 7 (Pts. # 1, 2, 7, 3, 4 and 6) clinical records reviewed. 4. Pt. #3 was admitted for home health services on 6/20/24 with the diagnosis of Unspecified Heart Failure. The clinical record was reviewed on 8/26/24. The clinical record contained the comprehensive assessment form titled, "OASIS-E Start of Care" completed by the RN and dated 6/20/24. This form included an immunization section requiring the RN to inquire and document the need for the Pneumonia vaccine. The record lacked documentation the RN offered the Pneumonia vaccine or consulted with the patient's primary Physician to assess whether the vaccine was previous administered, as required by the Agency. 5. Pt. #4 was admitted for home health services on 1/23/24 with the diagnosis of Unstageable Pressure Ulcer of Right Buttocks. The clinical record was reviewed on 8/28/24. The clinical record contained the comprehensive assessment form titled, "OASIS-E Start of Care" completed by the RN and dated 1/23/24. The immunization section of the form lacked documentation the RN offered the Flu/Influenza and Pneumonia vaccines or consulted with the patient's primary Physician to assess whether the vaccines was previous administered. 6. Pt. #6 was admitted to home health services on 11/27/23 with the diagnosis of Acute Systolic (Congestive) Heart Failure. The clinical record was reviewed on 8/28/24. The clinical record contained the comprehensive assessment form titled, "OASIS-E Start of Care" completed by the RN and dated 11/27/23. The immunization section of the form lacked documentation the RN offered the Flu/Influenza and Pneumonia vaccines or consulted with the patient's primary Physician to assess whether the vaccines was previous administered. 7. The Agency's policy titled; "Pneumococcal Vaccination Policy" was reviewed on 8/28/24. The policy included, "Instructions 1) For all patients admitted for home health services, the Registered Nurse shall document on the SOC OASIS and Comprehensive Assessment regarding the administration or arrangement for administration of a pneumococcal vaccination to each patient who is 65 years of age or older and who has not received this immunization prior to or upon service initiation, unless the patient refuses the offer for vaccination, or the vaccination is medically contraindicated. 8. The Agency's policy titled; "Influenza Vaccination Policy" was reviewed on 8/28/24. The policy included, "Instructions 1) For all patients admitted between October 1 to March 31, the Registered Nurse shall document on the SOC OASIS and Comprehensive Assessment regarding the administration or arrangement for administration of an Influenza vaccination to each patient who is 18 years of age or older and who has not received this immunization prior to or upon service initiation, unless the patient refuses the offer for vaccination, or the vaccination is medically contraindicated. 9. During interviews with the Administrator and Director of Nursing/Agency Supervisor on 8/28/24 at 11:35 AM and 1:45 PM, the Director of Nursing/Agency Supervisor stated if the Pt. or family member do not recall when or whether the Pt. received the flu and Pneumonia vaccines, depending on the referral source the RN is required to contact the primary Physician or the inpatient facility to obtain this information. During the same interview, both confirmed the above findings. 2. Pt. #2 was admitted for home health services on 7/23/24 with the diagnosis of Radiculopathy, sacral and sacrococcygeal region. The clinical record was reviewed on 8/26/24. The clinical record contained the comprehensive assessment form titled "OASIS-E Start of Care" completed by the RN and dated 7/23/24. This form included an immunization section requiring the RN to inquire regarding the need for the Influenza and Pneumococcal vaccines. The record lacked documentation, the RN offered the Influenza and Pneumococcal vaccines or consulted with the patient's primary Physician to assess whether the vaccine was previously administered. 3. Pt. #7 was admitted for home health services on 3/30/23 with the diagnosis of Type 1 diabetes mellitus without complications. The clinical record was reviewed on 8/26/24 and 8/28/24. The clinical record contained the comprehensive assessment form titled "OASIS-E Start of Care" completed by the RN and dated 3/30/23. This form included an immunization section requiring the RN to inquire regarding the need for the Influenza and Pneumonia vaccine. The record lacked documentation, the RN offered the Influenza and Pneumococcal vaccines or consulted with the patient's primary Physician to assess whether the vaccine was previously administered. Findings include: 1. Pt. # 1 was admitted for home health services on 6/21/24 with diagnosis of Essential Primary Hypertension. The clinical record was reviewed on 8/26/24. The medical record included the “OASIS -E Start of Care” dated 6/21/24 and completed by RN. The immunization section lacked documentation the RN offered the Flu/Influenza and Pneumonia vaccines or consulted with the patient’s primary Physician to assess whether the vaccines were previously administered.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. *[For LTC facilities at §483.73(a)(1):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a)(1):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a)(2):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Emergency Preparedness Plan was based on a facility and community risk assessment, utilizing an all hazards approach. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 7/26/21 at 1:00 PM. The plan lacked a facility and community based risk assessment, using an all hazards approach. 2. During an interview with the Administrator and the Director of Nursing on 7/28/21 at 1:45 PM, the Director of Nursing confirmed the above finding.

Recertification survey completed. Standard level deficiencies cited. A Focused Infection Control Survey (FIC) was conducted on 7/29/21. Standard level deficiency cited. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care SN = Skilled Nurse AM = Morning PM = Afternoon, Evening COVID-19 = Coronavirus 2019

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: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure staff screened Pts. for COVID-19, prior to providing Pt. care and services. This was found in 5 of 7 (Pts. #1, 2, 7, 3, and 4) clinical records reviewed. Findings include: 1. Pt. #1. SOC 7/13/21. Primary Diagnosis: Umbilical Hernia with Obstruction. The clinical record was reviewed on 7/26//21 at 2:00 PM. The record contained documentation the SN provided service on 7/13/21. The record lacked documentation the SN screened the Pt. for signs and symptoms of COVID-19 prior to providing service on this date. 2. Pt. #2. SOC 4/15/21. Primary Diagnosis: Heart Failure, Unspecified. The clinical record was reviewed on 7/26//21 at 2:45 PM. The record contained documentation the Home Health Aide provided service on 6/1/21, 6/8/21, and 7/13/21. The record lacked documentation the Home Health Aide screened the Pt. for signs and symptoms of COVID-19 prior to providing service on these dates. 3. Pt. #7. SOC 4/19/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 7/27//21 at 1:35 PM. The record contained documentation the SN provided service on 6/1/21. The record lacked documentation the SN screened the Pt. for signs and symptoms of COVID-19 prior to providing service on this date. The record also included documentation the Physical Therapist provided service on 4/20/21. The record lacked documentation the Physical Therapist screened the Pt. for signs and symptoms of COVID-19 prior to providing service on this date. 4. Pt. #3. SOC 5/24/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 7/27/21 at 11:30 AM. The record contained Physical Therapy Assistant visit notes dated 6/26/21 and 7/3/21 indicating that Pt. #3 received therapy services on those dates. The record lacked documentation that during those dates, the Pt. was screened for sign and symptoms of COVID-19 prior to the visits. 5. Pt. #4. SOC 6/1/21. Primary Diagnosis: COVID-19 Acute Respiratory Disease. The clinical record was reviewed on 7/27/21 at 3:21 PM. The record contained Physical Therapy Assistant visit notes dated 6/5/21, 6/9/21, 6/11/21, 6/16/21, 6/19/21 and 6/26/21, indicating that Pt. #4 received therapy services on those dates. The record lacked documentation that during those dates, the Pt. was screened for signs and symptoms of COVID-19 prior to the visits. 6. The Agency policy titled "COVID-19 Plan Effective March 2020" was reviewed on 7/27/21 at 9:45 AM and required, "Patient Screening: When making a home visit, the Agency shall identify patients at risk for having COVID-19 infection before or immediately upon arrival to the home..." 7. During an interview with the Administrator and Director Nursing on 7/28/21 between 1:45 PM and 2:30 PM, the above findings were confirmed. The Director of Nursing stated all staff, including those who are under contracted services, should conduct Pt. COVID-19 screenings prior to conducting visits, and the results of these screenings should be documented in the Patient's clinical record.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: . Based on a review of clinical records, Agency policy, and staff interview, it was determined the Agency failed to ensure forms were complete and accurate. This was found in 4 of 7 (Pts. #1, 2, 7, and 3) clinical record reviewed. Findings include: 1. Pt. #1. SOC 7/13/21. Primary Diagnosis: Umbilical Hernia with Obstruction. The clinical record was reviewed on 7/26//21 at 2:00 PM. The record contained a "Notice of Medicare Non-Coverage" document. The effective date coverage of the Patient's current home health services would end was left blank. This document was signed by the Pt., but not dated. 2. Pt. #2. SOC 4/15/21. Primary Diagnosis: Heart Failure, Unspecified. The clinical record was reviewed on 7/26//21 at 2:45 PM. The record contained a "Notice of Medicare Non-Coverage" document. The effective date coverage of the Patient's current home health services would end was left blank. This document was signed by the Pt., but not dated. 3. Pt. #7. SOC 4/19/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 7/27//21 at 1:35 PM. The record contained a "Notice of Medicare Non-Coverage" document. The effective date coverage of the Patient's current home health services would end was left blank. This document was signed by the Pt., but not dated. 4. Pt. #3. SOC 5/24/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 7/27/21 at 11:30 AM. The record contained a document which was signed by Pt. #3, titled "Notice of Medicare non-coverage." The record lacked entries on "Services will end effective:" and, also lacked the date on which Pt. #3 signed the document. 5. The Agency Policy titled "Patient Discharge Process" was reviewed on 7/28/21 at 1:30 PM. The policy required: "...Patients shall be issued a Notice of Medicare Non-Coverage at least 24 hours prior to termination of Home Health Services." 6. During an interview with the Administrator and Director of Nursing on 7/28/21 between 1:45 PM to 2:30 PM, the above findings were confirmed. The Director of Nursing stated that the forms should be filled out completely.