Every finding on record at Alfred Healthcare Services, Inc.

A recertification survey was initiated on 08/08/2022. The census was 53. Deficiencies cited. Abbreviations/Acronyms: Adm-Administrator Alt Adm-Alternate Administrator DON-Director of Nurses (Supervising Nurse) EP-Emergency Preparedness COVID-19- Novel Coronavirus Disease 2019

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 emergency preparedness requirements. The agency failed to maintain an emergency preparedness plan that was reviewed, and updated at least annually, in accordance with state regulation for two of two years reviewed (2020 and 2021). The failure could place the agency’s patients’ health, safety, and care at risk if the agency was not prepared in emergency or disaster situations. FINDINGS INCLUDED: During the entrance conference on 08/08/2022 at 11:15 a.m. the Adm self- identified as the Disaster Coordinator. The surveyor requested all agency EP records. The records were requested again at 12:30 p.m. and 1:30 p.m. The Adm provided an EP binder for the years 2019, 2020 and 2021. Review of the agency’s EP binder did not reveal that the agency had maintained an emergency preparedness plan that was reviewed, and updated at least annually, in accordance with state regulation for the years 2020 and 2021. The EP binder included a “Risk Assessment” dated 06/05/2018. The Binder did not include an updated risk assessment that included the COVID-19 pandemic for the years 2020 and 2021. The EP binder included two documents titled “Annual Emergency Preparedness Plan Evaluation.” The evaluations read in part: “…Emergency Preparedness Evaluation Plan for [Identifier 100, a different agency in the same location]. The evaluations were signed by the Adm and dated “12/16/21 and 12/14/20.” The evaluations did not show any changes or updates to include the COVID-19 pandemic. The binder also contained a document titled “Evaluation of Emergency Preparedness Implementation” that read in part: “…Actual Event…Date Implemented: 3-20-20 Reason Implemented: COVID-19-Pandemic, Strict Infection Control & know how to evaluate using checklist protocol…Emergency Preparedness Plan for [Identifier 100]. The evaluation was signed by the Adm and dated 04/20/2018. The last update “New ER preparedness updates” to the agency’s EP plan was listed as “2/5/19 and 02/19/19” on two documents titled “EP Plan and Program Annual Update Log.” During an interview with the Adm (Disaster Coordinator) and the Alt Adm/DON on 08/16/2022 at 12:15 p.m. the surveyor discussed the above findings of why the agency did not maintain an emergency preparedness plan that was reviewed, and updated at least annually, in accordance with state regulation for the years 2020 and 2021. The Adm stated that, although the documents had Identifier 100’s agency name on them the documents in the binder had his signature on them. The Alt Adm/DON replied, “Now we are knowing better. We will do better.” The surveyor also discussed how not updating the emergency plan, at least annually, could adversely affect the agency’s patients. The Alt Adm/DON replied, “It affects the patients care and the patient’s safety.” Review of agency policy titled, ““Emergency Preparedness and Response Plan EC.8” revised 070120 read in part: “PURPOSE I. To ensure the agency complies with all applicable Federal, State, and local emergency preparedness requirements. II. To ensure the Agency develops, establishes, maintains, and implements Emergency Preparedness policies and procedures, based on the risk assessment, emergency plan, that will be reviewed and updated at least annually…POLICY 1. The Agency will have a written preparedness and response plan that comprehensively describes identification of potential disasters, including infectious diseases, and its approach to a disaster that could affect the need for its services or its ability to provide those services. The written plan will be based on a risk assessment that identifies the disasters from natural and man-made causes that are likely to occur in the Agency’s service area and/or facility…VI. The Agency will involve the Administrator, Clinical Manager or Supervising Nurse, Disaster Coordinator, and Alternate Disaster Coordinator in the development, maintenance, and implementation of the emergency preparedness plan. The plan and related policies and procedures must be reviewed and updated at least annually…”

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain an emergency preparedness plan that was based on and included a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach for two of two years reviewed (2020 and 2021). The failure could place the agency’s patients’ health, safety, and care at risk if the agency was not prepared in emergency or disaster situations. FINDINGS INCLUDED: During the entrance conference on 08/08/2022 at 11:15 a.m. the Adm self-identified as the Disaster Coordinator. The surveyor requested all agency EP records. The records were requested again at 12:30 p.m. and 1:30 p.m. The Adm provided an EP binder for the years 2019, 2020 and 2021. Review of the agency’s EP binder did not reveal that the agency had maintained an emergency preparedness plan that was based on and included a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach for the survey review period of 2020 and 2021. The EP binder included a Risk Assessment” dated 06/05/2018. The Binder did not include an updated risk assessment that included the COVID-19 pandemic for the years 2020 and 2021. During an interview with the Adm and Alt Adm/DON on 08/16/2022 at 12:15 p.m. the surveyor discussed the above findings. The surveyor discussed why the agency did not maintain an emergency preparedness plan that was based on and included a documented, facility-based, and community-based risk assessment, utilizing an all-hazards approach for the years 2020 and 2021 that included the COVID-19 pandemic. The Alt Adm/DON replied, “Now we are knowing better. We will do better.” The surveyor also discussed how not updating the risk assessment could adversely affect the agency’s patients. The Alt Adm/DON replied, “It affects the patients care and the patient’s safety.” Review of agency policy titled, ““Emergency Preparedness and Response Plan EC.8” revised 070120 read in part: “PURPOSE I. To ensure the agency complies with all applicable Federal, State, and local emergency preparedness requirements. II. To ensure the Agency develops, establishes, maintains, and implements Emergency Preparedness policies and procedures, based on the risk assessment, emergency plan, that will be reviewed and updated at least annually…POLICY 1. The Agency will have a written preparedness and response plan that comprehensively describes identification of potential disasters, including infectious diseases, and its approach to a disaster that could affect the need for its services or its ability to provide those services. The written plan will be based on a risk assessment that identifies the disasters from natural and man-made causes that are likely to occur in the Agency’s service area and/or facility…”

A recertification survey was initiated on 08/08/2022. The census was 53. Deficiencies were cited with continuing deficiencies cited from survey dated 08/15/2019. Abbreviations/Acronyms: Adm-Administrator Alt Adm-Alternate Administrator DON-Director of Nurses (Supervising Nurse) ADON-Assistant Director of Nurses (Alternate Supervising Nurse) Registered Nurse (RN) Licensed Vocational Nurse (LVN) NOMNC- Notice of Medicare Non-Coverage POC/485- Plan of Care SOC- Start of Care HHA's- Home Health Agencies PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement OASIS -outcome and assessment information set SN- Skilled Nursing hha-Home Health Aide CMS- Center for Medicare and Medicaid Services EHR-Electronic Health Record ASAP-As Soon As Possible COVID-19- Novel Coronavirus Disease 2019 CDC-Centers of Disease Control

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure proper written notice was provided, in advance of terminating on-going care in two (Patients # 6 and 7) of two inactive patient records reviewed. The agency failed to provide Patients # 6 and 7 with the Centers for Medicare and Medicaid form titled Notice of Medicare Non-Coverage. The failure could affect patients’ health and safety and result in harm due to lack of physician oversight in the patients post discharge needs. FINDINGS INCLUDED: Clinical Record # 6: Record review of the hard copy record and EHR for Patient # 6 revealed a POC with a SOC date of 12/07/2019. The POC had a certification period 07/29/2021 to 09/26/2021 and a primary diagnosis of essential (primary) hypertension. The POC was signed by the Alt/Adm/DON and dated 07/26/2021. The POC contained an order for SN visits one time per week for nine weeks. Patient # 6's record included a discharge order signed by the Alt Adm/DON and dated 09/24/2021. The discharge order listed the reason for discharge as “patient is stable at this time with maximum potential reached.” The record also included a discharge OASIS dated 09/24/2021 and signed by the Alt DON. The OASIS listed the discharge date as 09/24/2021. Patient # 6's records did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 09/24/2021. The record did not include a written NOMNC. Clinical Record # 7: Record review of the hard copy record and EHR for Patient # 7 revealed a POC with a SOC date of 04/16/2021. The POC had a certification period 11/26/2021 to 01/24/2022 and a primary diagnosis of type 2 diabetes mellitus with diabetic chronic kidney disease. The POC was signed by RN # 3 and dated 11/22/2021. The POC contained an order for SN visits one time per week for nine weeks. Patient # 7's record included a discharge order signed by RN # 3 and dated 01/24/2022. The discharge order listed the reason for discharge as “goals/max potential reached.” The record also included a discharge OASIS dated 01/24/2022 and signed by RN # 3. The OASIS listed the discharge date as 01/24/2022. Patient # 7's records did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 01/24/2022. The record did not include a written NOMNC. In an interview with the Alt Adm/DON on 08/16/2022 at 11:45 a.m., the surveyor discussed the above findings of why the agency had not provided proper written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for Patients # 6 and 7? The Alt Adm/DON replied, “I didn’t know about that one. I was thinking about the 5-day [discharge notice].” The surveyor also discussed how not providing proper written notice, to the agency’s patients, of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care could adversely affect them. The Alt Adm stated it could affect the patients’ health and safety and it could cause lack of physician oversight [of their post discharge needs].” Agency policy titled “Patient/Client Transfer and Discharge Notices PE.6” revised 080120 read in part: “…Policy…I...Prior to transferring or discharging a patient/client, the Agency will provide written notification to the patient/client’s …legal representative…III. The Agency will deliver the Notice of Medicare Non-Coverage…to the patient/client (or authorized representative), at least two…calendar days before Medicare covered services end of the second to last day of service if care is not provided daily…”

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 record review and interview, the agency failed to ensure that a registered nurse conducted an initial assessment visit within 48 hours of referral in two (Clinical Records # 2 and # 3) of two patients with a diagnosis of hypertensive heart disease whose clinical records were reviewed. The failure could place the patients’ safety and well-being at risk if the patients had an exacerbation in their health condition during the days when the agency was not there to complete the assessment. FINDINGS INCLUDED: Clinical Record # 2: Record review of the hard copy record and EHR of Patient # 2 revealed a POC for the certification period of 05/14/2022 to 07/12/2022 with a SOC date of 03/15/2022. The POC had a primary diagnosis of hypertensive heart disease with heart failure and stage 1-4 kidney disease. The POC was signed by RN # 4 and dated 05/13/2022. The POC contained an order for SN visits one time per week for nine weeks. The hard copy record revealed a referral for home health services. The referral was dated 03/10/2022. Review of the EHR revealed a SOC OASIS/Initial visit date of 03/15/2022 over 120 hours (about 5 days) since the referral date. The initial visit was not conducted within 48 hours (due on 03/12/2022) of the referral date. There was no documentation/communication for why the initial visit was not conducted within 48 hours of the referral date of 03/10/2022. Clinical Record # 3: Record review of the hard copy record and EHR of Patient # 3 revealed a POC for the certification period of 05/10/2022 to 07/08/2022 with a SOC date of 05/10/2022. The POC had a primary diagnosis of hypertensive heart disease. The POC was signed by RN # 1 and dated 05/10/2022. The POC contained an order for SN visits two times per week for one week and one time per week for eight weeks. The hard copy record revealed a referral for home health services. The referral was dated 04/26/2022. Review of the EHR revealed a SOC OASIS/Initial visit date of 05/10/2022 over 336 hours (about 2 weeks) since the referral date. The initial visit was not conducted within 48 hours (due on 04/28/2022) of the referral date. There was no documentation/communication in the medical record for why the initial visit was not conducted within 48 hours of the referral date of 04/26/2022. During an interview with the Alt Adm/DON on 08/16/2022 at approximately 11:45 a.m. the surveyor discussed the above findings of why the agency did not conduct the initial assessment within 48 hours of referral. The Alt Adm/DON replied, “It could be from the patient [patient’s choice].” The surveyor also discussed how the patients could be negatively affected when an initial assessment visit was not conducted within 48 hours of referral. The Alt Adm/DON stated that the patients’ safety and well-being could be at risk if the patients had an exacerbation in their health condition during the days when the agency was not there to complete the assessment. Review of agency policy titled “Initial Patient/Client Assessment PE.6” reviewed 010122 read in part: “…Procedure…II. The initial visit will be conducted within… 48 hours of the referral…In instances where the patient/client requests a delay in the start of care date, The Agency will contact the physician…to request a change in the start of care date and such change will be documented in the medical record…” Review of agency policy titled “Patient/Client Assessment Guidelines PE.2” reviewed 010122 read in part: “…Procedure…IX. An assessment performed due to an intra-agency referral will be completed as follows: A. Nursing-…48 hours…”

Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This STANDARD is not met as evidenced by: Based on record review, observations, and interviews, the agency failed to provide written information in three (Patients # 1, # 2 and # 3) of three patients who received a home visit. The HHA failed to provide the patient and caregiver with a copy of written instructions which outlined: 1. Visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. 2. A current patient medication schedule/instructions that included: medication name, dosage and frequency and which medications would be administered by HHA personnel and personnel acting on behalf of the HHA. The failure could place the patients at risk of being uninformed and/or unable to identify the staff scheduled to provide care and services on behalf of the agency while in the patient's homes. The failure could place the patients and patient representative at risk of being uninformed of the patient's medication name, dosage and frequency and which medications might be administered by HHA personnel and personnel acting on behalf of the HHA. The failure could also cause the patient to be uninformed of their rights. Review of the agency's sample "Medicare" admission packet revealed that the sample packet contained a form for medication schedule/instructions. The admission packet did not include a form for visit schedules. Clinical Record # 1: Record review of the hard copy record and EHR for Patient # 1 revealed a POC for the certification period of 07/02/2022 to 08/30/2022 with a SOC date of 05/03/2022. The POC had a primary diagnosis of Varicose veins of right lower extremities with ulcer to other part of lower leg. The POC was signed by RN # 1 and dated 08/09/2022. The POC contained an order for SN visits one time per week for nine weeks. The POC also contained an order for hha visits for three times per week for eight weeks and one time per week for one week. During a home visit conducted on 08/10/2022 at approximately 10:00 a.m., the surveyor observed, and reviewed Patient # 1's home admission binder. The binder did not include a visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. The binder also did not include current medication schedule/instructions for the current certification period of 07/02/2022 to 08/30/2022. The binder had medication schedule/instructions from the date of admission 05/03/2022. Clinical Record # 2: Record review of the hard copy record and EHR of Patient # 2 revealed a POC for the certification period of 05/14/2022 to 07/12/2022 with a SOC date of 03/15/2022. The POC had a primary diagnosis of hypertensive heart disease with heart failure and stage 1-4 kidney disease. The POC was signed by RN # 4 and dated 05/13/2022. The POC contained an order for SN visits one time per week for nine weeks. During a home visit conducted on 08/10/2022 at approximately 11:30 a.m., the surveyor observed, and reviewed Patient # 2's home admission binder. The binder did not include a visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. The binder also did not include current medication schedule/instructions for the certification period of 05/14/2022 to 07/12/2022. The binder had medication schedule/instructions from the date of admission 03/15/2022. Clinical Record # 3: Record review of the hard copy record and EHR of Patient # 3 revealed a POC for the certification period of 05/10/2022 to 07/08/2022 with a SOC date of 05/10/2022. The POC had a primary diagnosis of hypertensive heart disease. The POC was signed by RN # 1 and dated 05/10/2022. The POC contained an order for SN visits two times per week for one week and one time per week for eight weeks. During a home visit conducted on 08/10/2022 at approximately 2:30 p.m., the surveyor observed, and reviewed Patient # 3's home admission binder. The binder did not include a visit schedule that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. The binder also did not include current medication schedule/instructions for the current certification period of 05/10/2022 to 07/08/2022. The binder had medication schedule/instructions from the date of admission 05/10/2022. During an interview with the Alt Adm/DON on 08/16/2022 at approximately 10:45 a.m., the surveyor discussed the above findings of why the agency had not provided a current visit schedule or medication schedule/instructions to Patients # 1, # 2 and # 3. The Alt Adm/DON stated that it was an oversight and “I will go through the new regulations, so I can update.” The surveyor also discussed how not providing agency patients with a current visit schedule or medication schedule/instructions could adversely affect them. The Alt Adm/DON replied, “We will improve on that one. It is important for them to be aware of these rights.”

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, as part of the QAPI program, the agency failed to conduct and document PIP(s) for three of three years reviewed (2019, 2020 and 2021) that reflected the scope, complexity and past performance of the agency's services and operations. The failure could prevent the agency from improving and providing quality care and services to the agency's patients, placing the agency’s patients’ health and safety at risk. FINDINGS INCLUDED: During the entrance conference on 08/08/2022 at 11:15 a.m., the surveyor requested all agency QAPI documents/reports/manuals. QAPI binders for 2019, 2020, 2021 and 2022 were provided. Record review of the binders showed that they contained Quality Assessment/Performance Improvement/Utilization Review Quarterly Reports, Infection Control Reports, and active and discharged client record audits. The quarterly QAPI reports included the following: 1st quarter 2022; 1st, 2nd, 3rd, and 4th quarters 2021; 1st, 2nd, 3rd, and 4th quarters 2020; and 3rd and 4th quarters 2019. The surveyor also reviewed the agency’s business profile binder. The binders and quarterly QAPI reports did not contain any reports, reviews nor documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements, for the years 2019, 2020 and 2021. The agency failed to document quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects for the years 2019, 2022 and 2021. During an interview on 08/16/2022 at approximately 11:00 a.m., with the Alt Adm/DON and Office Nurse (LVN), the surveyor discussed the above findings of why the agency had not conducted PIP(s) per federal regulatory requirements for the years 2019, 2020 and 2021. The Alt Adm/DON stated that he was not aware of the regulatory requirement to conduct performance improvement projects. The surveyor also discussed how this failure could adversely affect the agency’s patients. The Alt Adm/DON stated that the patients’ safety would be affected by the agency not being able to identify if the agency was providing “good care.” Review of agency policy titled "Performance Improvement Process: Improvement Activities QAPI.5” revised 011318 read in part: “…Policy II. The Governing Body will determine the number and scope of distinct Performance Improvement Projects… conducted annually. III. When developing and prioritizing the improvement projects, the Governing Body will consider…A. The scope, complexity, and past performance of the Agency's services and operations…IV. All performance improvement activities/projects undertaken will be documented and include the reasons for conducting these and the measurable progress achieved…”

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain a coordinated agency‐wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that was an integral part of the HHA's QAPI program. In one of one, infection control program, the program did not have a program/method for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases specific to care and services provided in the home setting (for the years 2020 and 2021). The failure could place agency clients at an increased risk of the spread of infectious and communicable diseases. The failure could also cause the agency to not identify trends in infections and therefore prevent the agency from developing action plans to prevent the trending infections. FINDINGS INCLUDED: During the entrance conference on 08/08/2022 at 11:15 a.m., the surveyor requested the agency’s infection control records. During the entrance conference the Alt Adm/DON stated that the agency had patients and staff members who had previously tested positive for COVID-19. On 08/08/2022, at 12:30 p.m. and 1:30 p.m., the surveyor again requested the agency’s infection control records. At 1:30 p.m. QAPI binders for 2019, 2020, 2021 and 2022 were provided. The Office Nurse (LVN) stated that the infection control records were in the QAPI binders. Record review of the QAPI binders did not reveal any surveillance records for COVID-19 infections. The binders included patient infection reports for urinary tract infection, skin infections and “other” infections. The binders did not include any reports for COVID-19 infections. At 3:00 p.m. the surveyor requested the agency’s patient and staff COVID-19 surveillance report. A report was not provided prior to the surveyor leaving the agency at 5:00 p.m. On 08/09/2022 at 11:15 a.m. the surveyor again requested the agency’s patient and staff COVID-19 surveillance report. The Alt Adm/DON stated that the Office Nurse (LVN) “is not aware of that report. It was not something that we did before. We have had a lot of turn over.” The agency failed to maintain an agency wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that was an integral part of the HHA's quality assessment and performance improvement program. During an interview with the Alt Adm/DON and the Office Nurse (LVN) on 08/16/2022 at approximately 11:00 a.m. the surveyor discussed the above findings and how the agency was not maintaining an agency wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases could adversely affect the agency’s patients. The Alt Adm/DON replied, “When we know their [infection] status, with that information we could plan better to avoid cross infection. We could plan better for their care.” Review of agency policy titled “Infection Control Program IC.2” revised 070120 read in part: “…Policy I. The Agency’s infection control program will be based on the following criteria…CDC guidelines…Current federal, state, and local laws and regulations…The Infection Control Program will include…C. A system that coordinates: 1. Surveillance for the occurrence of an infection 2. Identification of the occurrence 3. Implementing appropriate preventive procedures…[and] measures to control infection 5. Review of the data collected to evaluate for trends, patterns, etc. 5. Reporting the data and any identified trends as appropriate…D. Review and Reporting Activities…4. The Supervising Nurse or designee will review all reports and analyze data, noting trends or patterns and will report to the QAPI Committee quarterly…” The CDC defines surveillance as "the ongoing, systematic collection, analysis, interpretation and evaluation of health data closely integrated with the timely dissemination of this data to those who need it." https://www.cdc.gov/

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 a record review, observation and interview, the agency failed to ensure that each hha competency evaluation was performed by a registered nurse, in three of (hha # 1, # 2, and # 4) three home health aide's personnel records reviewed for competency evaluation. The failure could place agency patients’ safety and well-being at risk. The failure could also place the patients at risk of receiving unsafe hha care and services, if the hha was not competent to provide the ordered home health aide services. FINDINGS INCLUDED: Clinical Record # 1: Record review of the hard copy record and EHR for Patient # 1 revealed a POC for the certification period of 07/02/2022 to 08/30/2022 with a SOC date of 05/03/2022. The POC had a primary diagnosis of Varicose veins of right lower extremities with ulcer to other part of lower leg. The POC was signed by RN # 1 and dated 08/09/2022. The POC contained an order for SN visits one time per week for nine weeks. The POC also contained an order for hha visits for three times per week for eight weeks and one time per week for one week. Further review of Patient # 1’s clinical records revealed that hha (s) # 1, 2, and 4 had provided hha services for Patient # 1. Personnel Record hha # 1: Record review revealed hha # 1’s date of hire as 07/09/2021. The record did not contain a signed job description for the position of home health aide. The personnel record did not include any documentation to show that an RN had evaluated hha # 1’s home health aide competency. Patient # 1: Record review of Patient # 1’s clinical record revealed that hha # 1 had provided hha services for Patient # 1 on the following dates: 07/01/2022; 07/05/2022; 07/07/2022, and 07/08/2022. Personnel Record hha # 2: Record review revealed hha # 2’s date of hire as 07/08/2022. The record contained a signed job description for the position of home health aide and dated 07/08/2022. The personnel record did not include any documentation to show that an RN had evaluated hha # 2’s home health aide competency. Patient # 1: Record review of Patient # 1’s clinical record revealed that hha # 2 had provided hha services for Patient # 1 on the following dates: 07/ 11, 13, 14, 15, 18, 20, 22, 25, 27, 29/2022 and 08/ 01, 03/ 2022. Personnel Record hha # 4: Record review revealed hha # 4’s date of hire as 07/21/2022. The record contained a signed job description for the position of home health aide dated 08/02/2022. The personnel record did not include any documentation to show that an RN had evaluated hha # 4’s home health aide competency. Patient # 1: During a home visit with Patient # 1 the surveyor observed that hha # 4 provided hha services on 08/15/2022 at approximately 10:00 a.m. 08/09/2022 at approximately 12:00 p.m. the surveyor requested the agency’s in-service records. The Office Nurse (LVN) provided a copy of the agency’s hha in-service records. The records did not include any records that showed the hha’s were evaluated for competency prior to providing hha services to agency patients. On 08/09/2022 at approximately 3:20 p.m. the Adm stated that the agency’s employees hire date was “on the application.” The hire dates listed above were on the hha (s) applications. On 08/10/2022 at 3:34 p.m. the surveyor discussed with the Alt Adm/DON who conducted the agency’s hha competency evaluation program. The Alt Adm/DON stated that the Office Nurse (LVN) “has been doing it for them.” The surveyor also discussed what the agency used for hha competency evaluation program and requested a copy. The Office Nurse (LVN) provided a copy of the agency’s hha in-service records. The records did not include any records that showed the hha’s were evaluated for competency to provide hha services. During an interview on 08/15/2022 at approximately 4:00 p.m., the surveyor discussed how the hha(s) were oriented and evaluated for competency by the agency with Anonymous hha, Identifier # 5 and Identifier # 6. Identifier # 5 stated that Identifier # 5 met with the agency Adm and was provided information about the job and took a test. Identifier # 5 stated that an agency RN did not evaluate Identifier # 5’s competency in a patient’s home prior to providing hha services to agency’s patients. Identifier # 6 stated, “They went over everything with me, in the office, of what the job was about. I did take a test.” Identifier # 6 stated that an agency RN did not evaluate Identifier # 6’s competency in a patient’s home prior to providing hha services to agency’s patients. During an interview on 08/16/2022 at 11:10 a.m. with the Alt Adm/DON and Office Nurse (LVN), the surveyor discussed the above findings of why hha # 1, # 2, and # 4 did not receive a competency evaluation conducted by an agency RN. The Alt Adm/DON stated that for hha # 1 it was overlooked because she was assigned to Patient # 1 on impulse (hha # 1 was hired for marketing but was also a certified nurse aide) when the patient’s previous hha resigned from the agency. The Alt Adm/DON replied, “We will do better.” The surveyor also discussed how not ensuring hha # 2 and # 4’s competency was evaluated could adversely affect agency clients. The Alt Adm replied, “It affects their safety, their well-being and the care that we provide for them.” The Office Nurse (LVN) replied, “It will not let us know the ability of the individual. Their competency will not be determined, and it would affect the patient care.” Review of agency policy titled “Staff Competency HR.8” revised 010121 read in part: “Purpose To ensure competency of the patient/client care staff is assessed and improvement needs are identified on an ongoing basis. Policy [:] The Agency will determine competency of patient/client care staff utilizing a competency checklist. Competency will be assessed initially during orientation, as needed when new skills, procedures, techniques, or equipment are introduced and when an RN delegates a task to an unlicensed person. A discipline or skill specific competency checklist assessment will be performed by qualified individuals…V. The competency checklist will be completed and retained in the staff’s personnel file…” Review of agency policy titled “Home Health Aide…Competency Evaluation HR.9” revised 011318 read in part: “…Policy [:] The Agency will ensure that each home health aide successfully completes a home health aide competency evaluation in accordance with federal and state laws and regulations prior to performing care independently…Procedure…I…B. The competency evaluation will be administered by a registered nurse…G. The completed competency evaluations will be kept in the employee’s personnel file and may be administered annually as a skills review/check off…”