Every finding on record at Aline Home Health Care of Texas Inc

A Recertification survey was conducted on 12/11/2024. Licensed and Certified census was 0. Abbreviations/Acronyms: Admin-Administrator Alt-Alternate Admin Assist/CFO-Administrative Assistant/Chief Financial Officer Office Mgr.-Office manager EP-Emergency Preparedness

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 record review and interview, the agency failed to conduct an additional exercise at least every two years to test the emergency plan annually, for three (2021, 2022, and 2023) of three years reviewed. The failure placed the agency's patients at risk of harm related to lack of organized preparation and planning for patient care and services in the event of a disaster/emergency. Findings include: During the entrance conference at 3:20 p.m. on 12/11/2024, the Admin self-identified as the disaster coordinator and identified the Office Mgr. as the alternate disaster coordinator. Review of the undated emergency preparedness plan binder revealed that the agency activated (called the agency’s clients) its EP plan for weather events for 2021, 2022, and 2023. Continued record review of the emergency preparedness plan records did not identify any records to establish that the agency had conducted an additional exercise at least every two years to test the EP plan, with a full-scale exercise that is community-based or individual, facility-based functional exercise; or a mock disaster drill; or a tabletop exercise or workshop. During an interview on 12/20/2024 at 12:25 p.m. with the Admin and Office Mgr. the surveyor asked who was responsible for the agency’s EP program. The Office Mgr. stated that she was responsible. The surveyor asked the Office Mgr. to describe the agency’s EP program (EP plan) processes. The Office Mgr. stated that if there was a disaster the Alt disaster coordinator would be alerted and she would notify the Admin; the agency would call all clients, find a solution, and document. The surveyor reviewed the findings and asked why the agency had not maintained/implemented the agency’s EP plan, which included exercises, drills, or tabletop exercises to test its EP plan. The Office Mgr. stated that she did not think the agency had to “do it if we didn’t have Medicare patients.” The surveyor asked how the failure could adversely affect the agency’s clients. The Admin replied, “I cannot say exactly.” The Office Mgr. Replied, “They could fall between the cracks if they are not called.” Record review of agency policy titled "EMERGENCY PREPAREDNESS" revised 12/01/10 revealed that it was not updated to include federal regulatory requirements to conduct exercises to test the emergency plan annually in full-scale drills, tabletop and/or other drills.

A Recertification survey was conducted on 12/11/2024, with follow-up for survey conducted on 01/04/2022, and a complaint investigation for Intakes 110125; 1101018; and 108634. Licensed and Certified census was 0. Abbreviations/Acronyms: Admin-Administrator Alt-Alternate Admin Assist/CFO-Administrative Assistant/Chief Financial Officer Office Mgr.-Office manager PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement

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: This is a continuing deficiency cited at G 0658 at survey dated 01/04/2022. Based on record review and interview, the agency failed to conduct and document PIP(s) for the calendar years 2021, 2022, and 2023 that reflected the scope, complexity and past performance of the agency's services and operations. The failure placed the agency’s patients’ health and safety at risk if the agency did not identify and improve quality of care and service related to health and safety concerns. Findings included: During the entrance conference on 12/11/2024 at 3:20 p.m., the surveyor requested all agency QAPI documents/reports/manuals. Review of agency’s QAPI records revealed the following: 2024, 2023, and 2022 QAPI audit reports and QAPI meeting minutes for the agency's personal assistance services. Review of the agency’s QAPI records (reports and meeting minutes) did not reveal documentation that indicated the agency had: any quality improvement projects undertaken, the reason for conducting the projects, and the measurable progress on achieving the projects; any performance improvement projects either in development, ongoing or completed for each calendar year of 2021, 2022, and 2023. During an interview on 12/20 2024 at 12:23 p.m. with the Admin and Office Mgr., the surveyor asked who was responsible for the agency’s QAPI program. The Office Mgr. stated that she was responsible. The surveyor reviewed the findings and asked why the agency had not conducted PIP(s) per federal regulatory requirements for the years 2021, 2022, and 2023. The Office Mgr. replied, “I don’t know what that would be.” She stated that she did not know the agency had to maintain the QAPI program if the agency did not have Medicare patients. The surveyor asked how the failure could adversely affect the agency’s patients. The Office Mgr. replied, “It could prevent them from improving.” Review of undated agency policies titled, "Section: Improving Organizational Performance” PI: 2; PI: 3; and PI: 8 revealed that the undated policies were not revised to include the federal regulatory requirement beginning July 13, 2018, for conducting performance improvement projects annually.

A Recertification Survey entrance conference was conducted via the telephone on 12/28/2021 at 10:00 AM with the ADON. Census: LCHHS: 0 LHH: 0 PAS: 52 An exit conference was conducted on 01/04/2022 at 5:20 PM with the CFO. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. The agency was found in compliance with 42 CFR Part 484.22 Emergency Preparedness Requirements for Home Health Agencies and no deficiencies were cited.

A Recertification and Follow-Up survey entrance conference was conducted via telephone on 12/28/2021 at 10:00 AM with the ADON. Census: LCHHS: 0 LHH: 0 PAS: 52 An exit conference was conducted on 01/04/2022 at 5:20 PM with the CFO. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Deficiencies cited at standard level. ABBREVIATIONS Adm – Administrator ADON – Alternate Director of Nurses Alt – Alternate AM - Ante meridiem ANE – Abuse, Neglect, Exploitation CFO- Chief Financial Officer CFR – Code of Federal Regulations CMS - Centers for Medicare and Medicaid Services DADS- Department of Aging and Disability Services DC – discharge Dc’d – discharged DOB - Date of Birth DON - Director of Nurses EMR: electronic medical record HHA – Home Health Agency IQIES - Internet Quality Improvement and Evaluation System LCHHS - Licensed and Certified Home Health LHHS - Licensed Home Health Services No. - Number OASIS- Outcome and Assessment Information Set OM – Office Manager PAS- Personal Assistance Services PIP – Performance Improvement Project PM - Post meridiem prn - as needed POC - plan of care QAPI- Quality Assurance Performance Improvement QIO – Quality Improvement Organization RN - registered nurse SN - skilled nurse SNV – skilled nurse visit SOC – start of care

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 provide a completed written Home Health Change of Care Notice (FORM No. CMS-10280) in advance of terminating on-going care due to agency administrative decisions and staff shortages in seven of seven (Patient 2, 3, 4, 6 ,7, 8 and 12) patient records reviewed. The agency failed to provide the CMS form titled, “Home Health Change of Care Notice". This failure caused agency patients at risk of adverse health outcomes as the agency would not be providing the patients time to arrange for proper continued care prior to DC and continuity of care after DC from the HHA. Based on record review and interview, the agency failed to provide a completed written Notice of Medicare Non Coverage (FORM No. CMS 1012) no later than two days in advance of terminating on-going care whose reason for DC was goals met in two of two (Patient 5 and 11) DC’d patient records reviewed. The agency failed to provide the CMS form titled, “Notice of Medicare Non-Coverage". This failure prevented the patient from exercising the right to appeal the DC decision, if desired. FINDINGS INCLUDE: A patient LCHHS DC list was provided to the surveyor by the OM which included the following DC dates: Patient 3: 11/04/2019; Patient 4: 11/06/2019; Patient 5: 05/23/2019; Patient 6: 06/22/2019; Patient 7: 10/02/2019; Patient 8: 09/03/2019. Patient 2, 11 and 12 were not included on the DC list. Record review of agency OASIS validation reports (a report generated when HHA’s electronically submit OASIS data to CMS that reflects dates of skilled comprehensive assessments completed by the agency) reviewed by the surveyor in IQIES, indicated the agency submitted OASIS assessments as follows: Patient 2: SOC visit 08/01/2019; Patient 11: SOC visit 05/11/2019; Patient 12: SOC visit 09/07/2019. Patient 2: Record review of the paper record included a POC dated 08/01/2019 to 09/29/2019 with a SOC date of 08/01/2019. The record contained a DC Summary signed and dated by the ADON on 10/06/2020 that read in part, “…Reason for Discharge For Cause (coordination note required)…Discharge Instructions No SNV performed on 09/18/2019 as agency is unable to contact patient for scheduled appointments…” The record did not include a coordination note. The record did not include a DC OASIS. The record did not include a Home Health Change of Care Notice FORM No. CMS-10280. Patient 3: Record review of the paper record included a POC dated 08/03/2019 to 10/01/2019. The record contained a SN DC OASIS assessment dated on 10/04/2019 that included Patient 3’s name, DOB, medical record number, time in and out and discipline of person completing the assessment (RN). The rest of the SN DC OASIS assessment was blank and not signed. The record did not include a DC OASIS or a DC Summary. The record did not include a Home Health Change of Care Notice FORM No. CMS-10280. Patient 4: Record review of the paper record included a POC dated 07/10/2019 to 09/07/2019. The record did not include a POC that included the DC date of 11/06/2019. The record did not include a DC OASIS or a DC Summary. The record did not include a Home Health Change of Care Notice FORM No. CMS-10280. Patient 5: Record review of the paper record included one POC dated 03/25/2019 to 05/23/2019. The record contained an SN DC OASIS assessment signed and dated on 10/04/2019 by the ADON. The SN DC OASIS read in part, “…Reason for discharge Goals met…Patient discharged form home care effective 5/23/2019. Patient given 5 day notice on 05/13/2019. The SN unable to contact the patient 5/23/2019 for discharge from agency as she is out of service area…” The record included a DC Summary that read in part, “…Reason for Discharge Goals Met…” The record did not include a Notice of Medicare Non-Coverage FORM No. CMS 10123. Patient 6: Record review of the paper record included one POC dated 04/25/2019 to 06/23/2019. The record contained an SN DC OASIS assessment signed and dated on 06/22/2019 by the ADON. The SN DC OASIS read in part, “…Reason for discharge No longer homebound…The above assessment is based in part on the last SNV on 6/10/2019…Patient unavailable for personal reasons for skilled assessment and evaluation during period 06/19/2019-06/23/2019…” The record included a DC Summary that read in part, “…SN unable to complete a assessment, evaluation during period 06/19/2019 – 06/23/2019 as patient was unavailable for personal reasons. She is no longer homebound…” The record did not include a Home Health Change of Care Notice FORM No. CMS-10280. Patient 7: Record review of the paper record included a POC dated 08/02/2019 to 09/30/2019; the POC was four pages and only page one was included in the paper record. The record contained an SN DC OASIS assessment signed and dated on 10/02/2019 by the ADON. The SN DC OASIS read in part, “…No SNV performed on 10/02/2019. Patient discharged from agency at his request…” The record included a DC Summary that read in part, “…No SNV performed on 10/02/2019. Patient discharged from agency at his request…” The record did not include a Home Health Change of Care Notice FORM No. CMS-10280. During an interview with the OM on 12/30/2021 at 1:45 PM, the surveyor presented the above findings of why pages 2, 3 and 4 of the POC were not included in the paper records. The OM stated those were some of the records the agency could not get to. The OM stated the EMR provider had been called after the survey began and the EMR provider would not give the agency access to all the records. Patient 8: Record review of the paper record included one POC dated 07/15/2019 to 09/12/2019. The record contained an SN DC OASIS assessment signed and dated on 09/03/2019 by the ADON. The SN DC OASIS read in part, “…Reason for discharge For Cause…No SNV performed 09/03/2019 at the patient’s request…” The record included a DC Summary that read in part, “…Reason for discharge For Cause… No SNV performed 09/03/2019 at the patient’s request…” The record did not include a Home Health Change of Care Notice FORM No. CMS-10280. Patient 11: Record review of the paper record included one POC dated 10/13/2018 to 12/11/2018. The record did not include a POC that included the DC date of 02/09/2019. The record contained an SN DC OASIS assessment signed and dated on 02/09/2019 by the ADON. The SN DC OASIS read in part, “…Reason for discharge Other…SN unable to contact/locate patient at the time of discharge from home care…SN to the patient’s home for recertification assessment. Pt not available. No response to call or knock on the door. Patient discharged unexpectedly…” The record included a DC Summary that read in part, “…Goals Not Met…SN to the patient’s home 2/9/2019. No answer to repeated calls or knock on the door. SN later spoke with the patient who states he was home…Patient Condition…Unstable…Current Condition…Stable at this time…Discharge with goals met…” The record did not include a Notice of Medicare Non-Coverage FORM No. CMS 10123. The record did not include a Home Health Change of Care Notice FORM No. CMS-10280. Patient 12: Record review of the paper record included one POC dated 09/07/2019 to 11/05/2019. The record contained an SN DC OASIS assessment signed and dated on 10/23/2019 by the ADON. The SN DC OASIS read in part, “…Reason for discharge For Cause (coordination note required)…No SNV performed on 10/23/2019. Patient discharged at the patient’s request…” The record included a DC Summary that read in part, “…Reason for discharge For Cause (coordination note required)… No SNV performed on 10/23/2019. Patient discharged at the patient’s request…” The record did not include a Home Health Change of Care Notice FORM No. CMS-10280. Surveyor 1 conducted the entrance conference on 12/28/2021. During a telephone interview with Surveyor 1 on 12/29/2021 at 3:32, Surveyor 1 stated she arrived at the agency on 12/28/2021 and was informed by the OM the Adm was out of the country and the Alt Adm was sick and neither of them were available. Surveyor 1 stated the OM gave her a memorandum from the Adm that appointed the ADON as the interim administrator and, therefore; the entrance conference was conducted with the ADON via telephone at 10:00 AM. During a telephone interview with the ADON on 01/04/2022 at 3:06 PM, the surveyor presented the above findings of why the Adm and Alt Adm were unavailable in person or by telephone. The ADON stated the Adm was out of the country and the Alt Adm had been ill. The surveyor presented the findings of if the ADON was familiar and able to answer surveyor questions regarding the overall operations of the agency. The ADON stated, “No” but the surveyor could ask questions to the OM and CFO as she was mostly familiar with questions regarding patients. The surveyor presented the above findings of why the EMR of the LCHHS/Medicare patients were not available for the surveyor to review, but instead there were incomplete paper records. The ADON stated when she was in the agency office on a regular basis, the EMR was up and going and she was not aware it was not available for survey review at this time. During an interview with Surveyor 1 on 12/29/2021, Surveyor 1 stated during the entrance with the ADON on 12/28/2021 at 10:00 AM, Surveyor 1 asked if LCHHS records were electronic. The ADON stated the records had been archived and she would have to ask how to access them as the agency no longer had active Medicare patients. During an interview with the OM on 12/30/2021, the OM stated the paper records for the Medicare patients were copied and ready for the surveyor. The surveyor presented the above findings of why the records were not available to review electronically. The OM stated the agency didn’t use the EMR anymore and couldn’t get into the EMR to print all the records. During an interview with the ADON on 01/04/2022 at 3:06 PM, the surveyor presented the above findings of why the EMR was not available for surveyor review. The ADON stated when she was in the office on regular basis, the EMR was up and going and she was not aware that it was not available now. The ADON stated the agency had not been able to pay the bill for the EMR and she was not able to use it. During an interview with the OM on 01/04/2022 at 3:40 PM, the surveyor presented the above findings of why Patient 2, 11 and 12 were not included on the LCHHS DC roster but were on the agency’s OASIS validation reports in IQIES. The OM stated she would have to go look through the agency’s paper records for information. On 12/30/2022 at 4:15 PM, the OM stated she found bits and pieces of information on the patients. During an interview with the CFO on 01/04/2022 at 4:10 PM, the surveyor presented the above findings of why all the agency’s DC’d LCHHS patients were not included on the DC list. The CFO stated she believed when originally asked for the list, the agency had a DC list but the list had not been updated. The CFO stated the agency decided not to admit Medicare patients in 2019. The surveyor presented the above findings of when the agency decided not to admit LCHHS patients in 2019, why didn’t the agency save or print the complete patient records. The CFO stated she delegated that task to someone before the EMR was being shut off and that it did not get done. The CFO stated the agency understood they would still have access to the EMR if needed, but the agency did not have access. During an interview with the ADON on 01/04/2022 at 3:11 PM, the surveyor presented the above findings of why the DC visit for Patient 2, 5, 6 ,7, 8, 11 and 12 were not done in person. The ADON stated the agency did not have enough clinicians to keep up with the patients and there was no other option other than letting the patients know the agency could not service them anymore. The ADON stated most of the patient’s were DC’d over the phone because the agency did not have personnel to do the visits. The surveyor presented the above findings if the patients were given written DC notices in advance of DC. The ADON stated the patients were not given DC notices because the DC’s were done verbally and telephonically because the agency didn’t have the staff to service them. During an interview with the CFO and the OM on 01/04/2022 at 4:11 PM, the surveyor presented the above findings of why the DC’d patients did not receive an in-person DC visit. The OM stated the patients did not want anyone coming to see them. The CFO stated it was due to an agency staffing issue the patients said they didn’t need anyone coming so the ADON and Adm made the decision to DC all of them. The surveyor presented the above findings if the agency assisted the patients in finding another HHA. The CFO stated the agency did not assist them in finding another agency and all the patients knew they were being DC’d. The CFO stated the patients were not having any physical issues, were stable, and really didn’t even need skilled services at that point. Agency policy titled, "DISCHARGE/TRANSFER/REFERRAL OF PATIENTS PC.26" read in part: "…PURPOSE: To provide appropriate ongoing care, treatment and services, or discharge based on the patient’s care, treatment and/or service needs…To uphold the patient’s right to receive information about his/her care, treatment and services and to be involved in the decision-making process when appropriate…To ensure that continuity of care, treatment and/or services is maintained to meet the patient’s needs…POLICY…Discharge planning is a dynamic collaborative process that begins with admission to Agency and continues as an ongoing process in response to patient needs for care, treatment and /or services in an effort to promote positive patient outcomes…Agency retains responsibility and continues to provide care, treatment and/or services until an appropriate transfer or discharge can be completed. Any discharge…shall occur in an appropriate manner, ensuring that relevant information is communicated to appropriate parties and in such a way as to prevent harm to the patient…” Regulation: July 1, 2005, the new Medicare regulations, Benefits Improvement and Protection Act gave beneficiaries access to the new expedited determination process when their home health agency services were ending. There were two notices required by these regulations. The first was a generic notice called a Notice of Medicare Provider Non-coverage labeled "FORM No. CMS 10123" that the provider would be delivered at least two days prior to when a beneficiary's Medicare coverage of services was ending. The telephone number for the QIO was to be included in the notice. The second was a detailed notice, called a Detailed Explanation of Provider Non-Coverage that the provider would deliver to the beneficiary and the appropriate QIO only if the beneficiary requested an expedited review by the QIO of the decision that coverage for items and/or services should end. Medicare currently requires HHA’s to issue HHCCNs (CMS-10280) to Medicare beneficiaries receiving the home health care benefits for notification of plan of care changes. Consistent with the Medicare Condition of Participation and the 2nd Circuit Court’s decision in Lutwin v. Thompson regarding notification procedures, home health agencies must provide the HHCCN whenever they reduce or terminate a beneficiary’s home health services due to physician/provider orders or limitations of the HHA in providing the specific service. Notification is required for covered and non-covered services listed in the POC. The HHCCN must be issued before the discontinuation of all home health care. Reasons for ending home health care include administrative decisions, such as concerns for staff safety, staff shortage, closure of the HHA, or failure to meet face-to-face encounter requirements, or due to physician's orders to discontinue care or a lack of orders to continue care. The HHCCN lists the services or supplies that will be changed, and it gives you instructions on what you can do if you don’t agree with the change.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the evaluation and maintenance of an effective, ongoing , agency wide data-driven QAPI Program that included procedures for measurement and analysis of indicators and that addressed the frequency with which such measurement and analysis must occur in accordance with federal standards, regulations and the agency's policies for calendar years 2019, 2020 and 2021. This failure did not allow the agency to evaluate and document its effectiveness in providing safe care and services to patients and to assess agency operations based on measurable indicators. FINDINGS INCLUDE: Review of the agency's QAPI manual on 12/30/2021 revealed no evidence the agency implemented and maintained a QAPI Program that included procedures for measurement and analysis of indicators and that addressed the frequency with which such measurement and analysis for the years 2019, 2020 and 2021. Review of the agency’s bulletin board included a memorandum from the Adm dated 12/29/2021 that read in part, “…To: All Staff…I am traveling out of the country…and will be out of the office through February 26, 2022. I will resume duties February 28, 2022. [ADON]…is appointed “Interim Administrator” in my absence…all issues/matters should be referred to her attention as appropriate with the assistance of [OM] & [CFO]. They will need your cooperation and support for the day to day operation of the agency…[Alt Adm/DON] has not fully recovered from ill-health to assume responsibilities at this time…” Surveyor 1 conducted the entrance conference on 12/28/2021. During a telephone interview with Surveyor 1 on 12/29/2021 at 3:32 PM, Surveyor 1 stated she arrived at the agency on 12/28/2021 and was informed by the OM the Adm was out of the country and the Alt Adm was sick and neither of them were available. Surveyor 1 stated the OM gave her the memorandum from the Adm that appointed the ADON as the interim Adm and, therefore; the entrance conference was conducted with the ADON via telephone at 10:00 AM. During a telephone interview with the ADON on 01/04/2022 at 3:06 PM, the surveyor presented the above findings of why the Adm and Alt Adm were unavailable in person or by telephone. The ADON stated the Adm was out of the country and the Alt Adm had been ill. The surveyor presented the findings of if the ADON was familiar and able to answer surveyor questions regarding the overall operations of the agency. The ADON stated, “No” but the surveyor could ask questions to the OM and CFO as she was mostly familiar with questions regarding patients. During an interview with the CFO and the OM on 01/04/2022 at approximately 3:45 PM, the surveyor presented the above findings of why the agency failed to maintain a QAPI program with required elements for calendar year 2019, 2020 and 2021. The CFO stated all Medicare patients were DC’d from the agency in 2019 so the agency did not have any QAPI information for 2020 and 2021. Agency policy titled, "POLICY AND PROCEDURE MANUAL HOME HEALTH…IMPROVING ORGAINIZATION PERFORMANCE PI:6 DATA COLLECTION" read in part: "…PURPOSE: Data is collected to monitor the stability of existing processes, identify opportunities for improvement, identify changes that will lead to improvement, and sustain improvement. POLICY: The agency will collect data to monitor performance of areas targeted for study and to determine effectiveness of the change…Utilization Review: At least quarterly, appropriate health care professionals, representing all the scope of services provided in that quarter, will review a sample of both active and closed clinical records based on Agency’s record review criteria…Data collected will be integrated into the QAPI program to assist the Agency in identifying areas needing improvement and in the improvement process. Agency will maintain a written record of the quarterly utilization process with appropriate signatures.” Agency policy titled, " POLICY AND PROCEDURE MANUAL HOME HEALTH…IMPROVING ORGAINIZATION PERFORMANCE PI:5 AGENCY EVALUATION PROCESS" read in part: "…PURPOSE: To outline the process for performing an annual agency evaluation and assess Agency’s program for appropriateness, adequacy, effectiveness, and efficiency. POLICY: Agency leaders…will participate in an annual evaluation of the organization’s performance in relation to its written organizational plan, mission, vision and philosophy. Findings will be utilized to correct identified problems…” Agency policy titled, " POLICY AND PROCEDURE MANUAL HOME HEALTH…LEADERSHIP LD:18 REGULATORY COMPLIANCE" read in part: "…POLICY: Agency complies with all applicable federal, state and local laws and regulations regarding all aspects of home health business practices. The Administrator is ultimately responsible for ensuring Agency compliance with all applicable…regulations…”

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, the agency failed to conduct and document PIP(s) for calendar year 2019 that reflected the scope, complexity and past performance of the agency's services and operations. The failure placed the agency at risk to not improve and provide quality care and services to the agency's patients. Findings Include: Record review of the agency's QAPI manual did not reveal any reports, reviews or documentation that indicated the agency had conducted PIP, per federal regulatory requirements, for the year 2019. The agency’s last L&C patient was discharged in 2019. Review of the agency’s bulletin board included a memorandum from the Adm dated 12/29/2021 that read in part, “…To: All Staff…I am traveling out of the country…and will be out of the office through February 26, 2022. I will resume duties February 28, 2022. [ADON]…is appointed “Interim Administrator” in my absence…all issues/matters should be referred to her attention as appropriate with the assistance of [OM] & [CFO]. They will need your cooperation and support for the day to day operation of the agency…[Alt Adm/DON] has not fully recovered from ill-health to assume responsibilities at this time…” Surveyor 1 conducted the entrance conference on 12/28/2021. During a telephone interview with Surveyor 1 on 12/29/2021 at 3:32, Surveyor 1 stated she arrived at the agency on 12/28/2021 and was informed by the OM the Adm was out of the country and the Alt Adm was sick and neither of them were available. Surveyor 1 stated the OM gave her the memorandum from the Adm that appointed the ADON as the interim Adm and, therefore; the entrance conference was conducted with the ADON via telephone at 10:00 AM. During a telephone interview with the ADON on 01/04/2022 at 3:06 PM, the surveyor presented the above findings of why the Adm and Alt Adm were unavailable in person or by telephone. The ADON stated the Adm was out of the country and the Alt Adm had been ill. The surveyor presented the findings of if the ADON was familiar and able to answer surveyor questions regarding the overall operations of the agency. The ADON stated, “No” but the surveyor could ask questions to the OM and CFO as she was mostly familiar with questions regarding patients. During an interview with the CFO and the OM on 01/04/2022 at approximately 3:54 PM, the surveyor presented the above findings of what the agency's PIP had been for calendar year 2019. The CFO stated she did not know but the Adm probably would. Agency policy titled, " POLICY AND PROCEDURE MANUAL HOME HEALTH…IMPROVING ORGAINIZATION PERFORMANCE PI:2 SENTINEL EVENTS” read in part: " ...PURPOSE: To promote patient safety by identifying and reducing the risk of sentinel events…POLICY: Agency chooses at least one (1) high-risk process annually to monitor, analyze and restructure/redesign, if necessary, to minimize the potential of negatively impacted patient safety…”