Every finding on record at Alcomed Homehealth Services Inc

Purpose of visit: Recertification survey Entrance: 04/12//2021 at 11:45 AM Agency census: L&C-8 LHHS-0 PAS-19 Exit: 04/22/2021 at 3:00 PM An exit conference was conducted with the Administrator/DON and the Alternate Administrator/ADON on 04/22/2021 at 3:00 PM. The preliminary findings were discussed. The agency was afforded an opportunity to provide additional information within two business days. Written instructions were provided to the Administrator for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviation List: POC- Plan of Care DON- Director of Nurses ADON- Alternate Director of Nurses SN- Skilled Nurse RN- Registered Nurse COBP- Continuity of Business Plan ER- Emergency EP- Emergency Preparedness

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to comply with all applicable Federal, State and local EP requirements to develop, establish and maintain a comprehensive EP program that met the requirements to maintain an EP plan that was reviewed, and updated at least every 2 years (per federal regulation) or at least annually (per state regulation and agency policy) for the years 2019 and 2020. The failure could place the agency's patients at risk of harm, in the event of an actual emergency or disaster, if the agency's emergency plan was not comprehensive and updated to meet applicable federal, state and local EP regulatory requirements and to meet the needs of the agency's patient population. FINDINGS INCLUDED: Review of the contents in the agency's "Emergency Preparedness" binder showed no evidence the agency conducted an annual review of the emergency preparedness plan for calendar years 2019 and 2020. Review of agency forms titled, "ANNUAL AGENCY EVALUATION" dated 01/04/2020 for the year ending 2019 and dated 01/03/2021 for the year ending 2020. The forms showed no evidence the agency conducted an annual review of the emergency preparedness plan for the calendar years 2019 and 2020. In an interview with the Administrator/DON on 04/22/2021 at approximately 2:00 PM, the surveyor reviewed the findings and asked if an annual review of the emergency preparedness plan was completed for calendar years 2019 and 2020. The Administrator/DON stated, "I thought they were the agency's Annual evaluations, no (ER plan) was evaluated, we have the forms. We were concerned and overwhelmed with COVID and trying to put out up to date information to clients. Our priority was COVID." Review of the agency's policy and procedure manual revealed a policy labeled, "EC. 8 Emergency Preparedness Policy and Plan... Policy... E. An annual review of the Emergency Plan and Communication Plan will be documented to include the date of the review and any updates made to the Emergency Plan or Communication Plan based on the review...."

Purpose of visit: Recertification survey Entrance: 04/12//2021 at 11:45 AM Agency census: L&C-8 LHHS-0 PAS-19 Exit: 04/22/2021 at 3:00 PM An exit conference was conducted with the Administrator/DON and the Alternate Administrator/ADON on 04/22/2021 at 3:00 PM. The preliminary findings were discussed. The agency was afforded an opportunity to provide additional information within two business days. Written instructions were provided to the Administrator for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviation List: POC- Plan of Care DON- Director of Nurses ADON- Alternate Director of Nurses SN- Skilled Nurse RN- Registered Nurse COBP- Continuity of Business Plan ER- Emergency EP- Emergency Preparedness

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to provide the patient and/or caregiver with written information outlining a visit schedule including frequency of visits by home health staff. In 3 (Patients #1, #2 and #4) of 3 patient home folders reviewed during a home visit, the agency failed to provide a written visit schedule to the patients. This failure placed the patients at risk of missed visits by staff when visits were not scheduled and conflicted with other appointments and the availably of the patients. FINDINGS INCLUDE: Patient #1: Record review of the clinical record contained a POC with a SOC date of 10/02/2020 and a certification period of 01/30/2021-03/30/2021. The POC included a principal diagnosis of Hyperglycemia and the following additional diagnosis: Hypertension and other Chronic Pain. The POC contained the following physician orders: SN to visit once a week for 9 weeks and hha services twice a week for eight weeks, then once a week for one week. Review of the record revealed no evidence that a visit schedule had been provided to Patient #1. On 04/15/2021 a home visit was conducted with Patient #1. The patient's home folder was reviewed. The surveyor asked Patient #1 if any paperwork had been removed from the patient's home folder. Patient #1 indicated nothing had been removed. The surveyor asked Patient #1 if the agency had provided a written visit schedule to show when the SN or hha would be visiting. Patient #1 stated, "I know to expect the nurse on Wednesdays, if she doesn't come on Wednesday, she will text and let me know." Patient #1 stated the aide usually came on Fridays. The surveyor asked if the agency had provided a written schedule showing when they were going to visit? Patient #1 stated, "No." Patient #2: Review of the clinical record contained a POC with a SOC date of 08/22/2019 and a certification period of 02/12/2021 to 04/12/2021. The POC included a principal diagnosis of Bilateral Osteoarthritis of knee and the following additional diagnoses: Hypertension and Calculus of Bladder. The POC contained a physician order for the SN to visit once a week for nine weeks. Review of the record revealed no evidence that a visit schedule had been provided to Patient #2. On 04/15/2021 a home visit was conducted with Patient #2. The patient's home folder was reviewed. The surveyor asked if any paperwork had been removed from the patient's home folder. Patient #2 said, "No." The surveyor asked Patient #2 if the agency had provided a written visit schedule to show when the SN would be visiting? Patient #2 stated, "I've been with the agency a long time, the nurse usually calls before she comes, otherwise she just comes out." The surveyor asked if the agency had provided a written schedule showing when they were going to visit? Patient #2 stated, "No." Patient #4: Review of the clinical record contained a POC with a SOC date of 01/10/2019 and a certification period of 12/30/2020-02/27/2021. The POC included a principal diagnosis Chronic Bronchitis and the following additional diagnoses: Artificial knee and Hypertension. The POC contained the following physician orders: SN once a week for one week and hha visits twice a week for eight weeks and once a week for one week. Review of the record revealed no evidence that a visit schedule had been provided to Patient #4. On 04/15/2021 a home visit was conducted with Patient #4. The patient's home folder was reviewed. The surveyor asked Patient #4 if any paperwork had been removed from the patient's home folder. Patient #4 stated nothing had been removed. The surveyor asked Patient #4 if the agency had provided a written visit schedule to show when the SN or hha? Patient #4 stated, "the RN usually calls prior to the visit, she usually comes at the same time. The nurse also helps me with all my personal care." The surveyor asked if the agency had provided a written schedule showing when they were going to visit? Patient #4 stated, "No." In an interview with the Administrator/DON on 01/22/2021 at approximately 12:30 PM, the surveyor reviewed the findings from the home visits. The surveyor asked why the agency failed to provide written visit schedules to Patient #1, 2 and 4? The Administrator/DON stated, "Once I do the recert (recertification assessment), I tell the patient how often the SN will be coming out and the 485 (POC) describes the frequency of the visits."

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on record review and interviews, the agency failed to provide patients with written medication schedule/instructions. In 3 (Patient's #1, 2 and 4) of 3 patients home folders reviewed during a home visit, the agency failed to provide a medication schedule with instructions written in plain language, without medical abbreviations, to the patients. This failure placed the agency's patients at risk of adverse effects, drug reactions, ineffective drug therapy, significant side effects, drug interactions, duplicated drug therapy and noncompliance with drug therapy. FINDINGS INCLUDE: Patient #1: Record review of the clinical record contained a POC with a SOC date of 10/02/2020 and a certification period of 01/30/2021-03/30/2021. The POC included a principal diagnosis of Hyperglycemia and the following additional diagnosis: Hypertension and other Chronic Pain. The POC listed 5 different medications. Review of the record revealed no evidence a medication schedule/instructions written in plain language had been provided to Patient #1. On 04/15/2021 a home visit was conducted with Patient #1. The surveyor reviewed the patient's home folder and asked if any paperwork had been removed from the folder. Patient #1 stated nothing had been removed. The surveyor asked about the patient's medications. Patient #1 stated, "I take my own medications, I don't have that many." The surveyor found no evidence of a medication list for Patient #1, written in plain language in the patients' home folder. Patient #2: Review of the clinical record contained a POC with a SOC date of 08/22/2019 and a certification period of 02/12/2021 to 04/12/2021. The POC included a principal diagnosis of Bilateral Osteoarthritis of knee and the following additional diagnoses: Hypertension and Calculus of Bladder. The POC listed 16 different medications. Review of the record revealed no evidence a medication schedule/instructions written in plain language had been provided to Patient #2. On 04/15/2021 a home visit was conducted with Patient #2. The surveyor reviewed the patient's home folder and asked if any paperwork had been removed from the folder. Patient #2 stated nothing had been removed she they knew of and stated, "I've been with them (agency) a long time." The surveyor asked about the patient's medications. Patient #2 stated, "I take my own medications, either I fill the pill box or my daughter does." The surveyor found no evidence of a medication list for Patient #1, written in plain language in the patients' home folder. Patient #4: Review of the clinical record contained a POC with a SOC date of 01/10/2019 and a certification period of 12/30/2020-02/27/2020. The POC included a principal diagnosis Chronic Bronchitis and the following additional diagnoses: Artificial knee and Hypertension. The POC listed 14 different medications. Review of the record revealed no evidence a medication schedule/instructions written in plain language had been provided to Patient #4. On 04/14/2021 a home visit was conducted with Patient #4. The surveyor reviewed the patient's home folder and asked if any paperwork had been removed from the folder. Patient #4 stated, "not that I'm aware of." The surveyor asked about the patient's medications. Patient #4 stated, "I can take my own medications. I'm legally blind, but have learned the sound of pills in the bottles." The surveyor found no evidence of a medication list for Patient #4, written in plain language in the patients' home folder. In an interview with the Administrator/DON on 04/22/2021 at approximately 12:30 PM, the surveyor reviewed the findings from the home visits. The surveyor asked why the agency had not provided medication schedules with instructions written in plain language to Patients #1, 2 and 4? The Administrator/DON stated he was not aware of the requirement for the medication list to be provided to the patients in plain language.

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure each of the tasks listed at 484.80(b)(3) were evaluated by observation of the home health aides' (hha) performance of the tasks for 1 of 1 hha personnel record reviewed. The competency evaluation was not completed by observation of the hha's performance of all the required tasks. This failure placed the patients that receive hha services and any future patients with assigned hha services at risk for receiving substandard or unsafe care from the home health aide. FINDINGS INCLUDE: An agency personnel roster was provided to the surveyor on 04/12/2021 by the Administrator/DON. The roster listed the hha as the only hha employed by the agency. Personnel record, hha: Review of the record revealed a form titled, "HOME HEALTH AIDE COMPETENCY SKILLS EVALUATION" signed by the Administrator/DON and dated 04/16/2018. The form included the name of the hha written on the top of the page 1 and the following multiple-choice question topics: "... III. Partial Bath (only 1 type required) A. Sponge, B. Tub, C. Shower, Comments:"- the task of Sponge was check marked as "Satisfactory"; "IV. Shampoo (only 1 type required) A. Sink, B. Tub, C. Bed, Comments:"- the task of Bed was check marked as "Satisfactory". Review of the entire hha personnel record and documents provided to the surveyor did not demonstrate evidence that the hha performed or was observed providing all the required tasks for a competency evaluation. Patient #1: Review of the clinical record included a hha Care Plan completed by the Administrator/DON and dated 01/29/2021. The hha Care Plan included the following assigned tasks to be completed with Patient #1 each visit: "... Tub/Shower... Hair care..." The record included hha visit notes for the following days: 02/05/2021; 02/12/2021; 02/19/2021 and 02/26/2021. Patient #5: Review of the clinical record included a hha Care Plan completed by the Administrator/DON and dated 10/30/2020. The hha Care Plan included the following assigned tasks to be completed with Patient #5 each visit: "... Bedbath; Partial sponge; Tub/Shower... Hair care..." The record included hha visit notes for the following days: 01/01/2021; 01/08/2021; 01/15/2021; 01/22/2021; 01/29/2021; 02/05/2021; 02/12/2021; 02/19/2021 and 02/26/2021. In an interview with the Administrator/DON on 04/22/2021 at approximately 12:30 PM, the surveyor reviewed the findings and asked why the agency did not ensure the hha was competency evaluated for all the required tasks. The Administrator/DON stated, "yes, the hha was only checked off on one type of bath and shampoo but this particular client did not have all the tasks and thorough instructions were given on the other tasks." "Code of Federal Regulations 484.80(c)1... The following skills must be evaluated by observing the aide's performance while carrying out the task with a patient.... (i) Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff; (iii) Reading and recording temperature, pulse, and respiration; (ix) Appropriate and safe techniques in performing personal hygiene and grooming tasks that include: (A) Bed bath; (B) Sponge, tub, and shower bath; (C) Hair shampooing in sink, tub, and bed; (D) Nail and skin care; (E) Oral hygiene; (F) Toileting and elimination;..." Agency Policy, revised date 09/01/2014, quoted in part, "HOME HEALTH AIDE COMPETENCY EVALUATION HR. 8... PURPOSE: To establish competency evaluation checklists for both written and skills demonstration. Policy: Agency will ensure that each home health aide successfully completes a home health aide competency evaluation prior to performing care independently in accordance with federal and state laws and regulations...."