Every finding on record at All About Care Homehealth Services Inc

A recertification survey was conducted on 07/23/2024. The census was 2 Licensed and Certified patients. An exit conference was conducted on 07/26/2024. The agency was in compliance with the Conditions of Participation for Emergency Preparedness.

Recertification survey was conducted on 07/23/2024. The census was 2 Licensed and Certified patients, An exit conference was conducted on 07/26/2024. Abbreviations: DON – Director of Nurses OASIS – Outcome Assessment and Information Data Set POC- Plan of Care QAPI – Quality Assurance Performance Improvement RN- Registered Nurse LVN – Licensed Vocational Nurse COVID 19 – Coronavirus disease 2019

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to electronically transmit each completed OASIS (a comprehensive assessment tool used by CMS to collect certain patient information) to the CMS system within 30 days of completing the assessments for 6 of 6 assessments transmitted from 07/22/2022 to 07/24/2024. Failure of the agency to transmit OASIS data within the required time frame prevented the agency’s patient data from being made available to CMS for analysis to evaluate the agency performance levels in the provision of patient care. The surveyor reviewed the OASIS Error Detail Report for the agency in the IQIES portal on 07/23/2024, as part of the preparation for the survey. The report documented 6 late assessments transmitted from 09/16/2022 to 05/09/2024 were submitted more than 30 days after the M0090 (the date of completion of the assessment.) During the entrance conference on 07/23/24, the surveyor noted the late submissions found during survey preparation and asked for OASIS final validation reports for the last two years. The surveyor reviewed the OASIS Agency Final Validation reports provided by the Office Manager on 07/26/2024. The records revealed 6 oasis validation reports with the error message “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” An interview was conducted with Alternate Administrator on 07/23/24 at 11:00 AM. The surveyor reviewed the late transmissions of OASIS assessments with the Alternate Administrator. The surveyor asked who was responsible for transmitting the assessments. The Alternate Administrator stated he did the transmissions, and he transmitted every two weeks. The Alternate Administrator stated they had delays in completing and reviewing the documentation by the clinicians that caused the delays. Additional information regarding the delays in transmission were not provided by the end of the survey. Agency policy titled: “IM.10 Timeliness revised date: 112910” read in part: POLICY -Agency will ensure timely provision of care and services to meet the patient's needs in compliance with all federal and state laws and regulations. PROCEDURE - A. All Agency staff, and physician/physician office staff as appropriate, will be oriented to the following parameters: 1. Evaluation visit for admission to Agency is within 48 hours of referral, discharge from hospital or on physician specific start of care order date. 2. Admission paperwork is completed within 2 days of admission to Agency. 3.Plan of care is established within 3-5 days of admission to Agency. 4. A Registered Nurse will complete the Initial Comprehensive Assessment no later than five (5) calendar days after the start of care (SOC) date for all patients in a licensed and certified agency… Encoding and submission of OASIS data to the state at least monthly and prior to billing…. “

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on observation, record review, and interview the agency failed to document both the existence of the complaint and the resolution of the complaint for 2 (Patient 2 and 3) of 7 patient records reviewed. Patients’ complaints about services were not addressed and resolved which violated the patient’s rights. This placed the patients at risk of further abuse, neglect or exploitation. Review of the complaint logs provided by the agency on 07/23/2024 revealed no complaints were documented for 2022, 2023, and 2024. The surveyor made a home visit on 07/23/2024 at 3:20 PM to the residence of Patient 2. The surveyor observed Patient 2 had with a splint on her left wrist. The surveyor asked Patient 2 about her wrist. Patient 2 stated she had fallen and fractured her wrist on 07/03/24 and had surgery on it. Patient 2 stated she was unable to use her walker as the left arm was non-weight bearing at this time. Patient 2 opened the splint and showed the surveyor the incision on her left wrist. Patient 2 changed the soiled gauze dressing over the incision during the visit. Patient 2 stated she has been asking for help with bathing because she can’t use her left hand. Patient 2 stated she was afraid to get into the shower without assistance and Patient 2 stated her nurse had called the office two times during different weekly visits to ask for the additional help. The surveyor asked if the patient had ever made a complaint to the agency. Patient 2 stated they had called the office and complained twice about not getting the Home Health Aide services requested, first in June 2024 and again in July 2024 and they had not resolved her issues. Patient 2 stated it was no use calling the office since they didn’t resolve the concerns, so Patient 2 next told the nurse who sees her weekly. The Patient stated the nurse called the office two weeks in a row in July 2024 while in Patient 2’s home to relay the Patient’s complaints and request for assistance. Review of Patient 2’s plan of care for the certification 05/21/2024 to 07/19/2024 revealed Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Abnormalities of gait and mobility (deviations from normal walking and movement which can affect balance). Review of Patient 2’s clinical record revealed a Comprehensive assessment completed on 07/15/2024 and signed by the DON. A review of the comprehensive assessment failed to find any information about the client’s complaints to the agency regarding the need for more assistance since July 3,2024 when Patient 2 fractured her arm. Review of Patient 2’s therapy note by PTA A documented a missed visit on 07/06/2024 due to the patient falling and breaking her left wrist. Review of Patient 2’s nurses note dated 07/11/2024 by LVN B documented the nurse conferenced with the DON regarding the client’s recent fall. Review of Patient 2’s nurses note dated 07/17/2024 by LVN B documented the nurse conferenced with the DON regarding the patient’s request for home health aide services. An interview was conducted with the DON, Administrator, and the Office Manager on 07.26.24 at 11:30 AM. The surveyor shared the findings from the record reviews and home visits. The surveyor asked why Patient 2 did not have an update to the comprehensive assessment after July 3 fall. The Supervising Nurse stated: “I didn’t know” about the fall, fracture, and surgery. The surveyor asked about the Comprehensive assessment documented on 07/15/2024 and signed by the DON. The DON stated: “I don’t remember this one.” The surveyor asked if the DON went to the patient’s home and completed the assessment dated 07/15/2024. The Supervising Nurse stated: “No I didn’t see her. I reviewed the assessment after talking with LVN B.” The surveyor asked about the client’s requests for help with bathing and complaints about not being provided the home health aide services needed. The Office Manager stated the client wanted home health aide services three times per week and insurance coverage was the problem. The surveyor asked why an OT evaluation was not requested after the client’s injury and request for assistance with bathing. The Supervising Nurse shrugged and did not respond. The Office Manager stated she did not know, and they would take care of it. The surveyor asked who was responsible for documenting complaints. The Office Manager stated she was. The Administrator stated he did not have anything else to add to explain or correct the findings. Review of discharged Patient 3’s record revealed a start of care of 10/27/2022 for Ovarian Cancer (a cancer of the female organs that produce eggs [ovaries]), Adult Failure to thrive (a syndrome of wight loss, decreased appetite, inactivity, often with dehydration, depressive symptoms, and impaired immune response), and Anemia (when the blood doesn’t have enough healthy red blood cells that carry oxygen throughout the body.) that was completed by PT A. The Plan of Care contained orders for a home health aide three times per week for 8 weeks. A review of the entire record found no home health aide services were provided. The record documented the patient complained about the lack of services on 11/07/2022 and requested a discharge of services because the agency didn’t provide the home health aide services. The surveyor requested and reviewed the Complaint log for October 2022 on July 5, 2023. There were no complaints documented on the complaint log for October 2022. An interview was conducted with the DON, Administrator, and the Office Manager on 07.26.24 at 11:30 AM. The surveyor shared the findings from the record reviews and home visits. The surveyor asked about the complaint by Patient #3. The Office manager stated: ‘We couldn’t provide services and we have had an issue with understanding the program. If it was a complaint due to discharge, I didn’t think of it as a complaint.” No additional information, response, or comment was provided by the DON or the Administrator to explain or correct the findings. Agency policy titled: “RI.6 RESOLUTION OF PATIENT CONFLICTS, GRIEVANCES OR COMPLAINTS Revised date: 091011” read in part: PURPOSE - To establish a procedure and ensure the patient's/caregiver's and or guardian's right to voice conflicts, file a complaint, and provide and to make recommendations for resolutions of conflicts without fear of retaliation, coercion, discrimination, reprisal or unreasonable interruption of care. POLICY Agency will receive, document, address and resolve conflicts that involve complaints made by a patient, a patient's family or guardian, or a patient's health care provider. Agency will provide a written statement that informs the patient/caregiver of the complaint procedure at time of admission. Agency will not retaliate against a person for filing a complaint, presenting a grievance, or providing, in good faith, information relating to services provided by Agency…Procedure A. Agency will investigate complaints made by a patient, a patient's family or guardian, or a patient's health care provider regarding: 1. Treatment or care that was furnished by Agency 2. Treatment or care that Agency failed to furnish 3. Lack of respect for the patient's property by anyone furnishing services on behalf of the Agency…E. Agency will complete the investigation and document all components of the investigation within 30 days after the receipt of the complaint, unless Agency has and documents reasonable cause for the delay. F. Agency will involve the patient/caregiver and/or the patient's physician as appropriate to reach a resolution. G. Agency will consider all patient/caregiver recommendations to reach a resolution… All actions taken and follow-up performed will be documented on the complaint form, as well as reported to the management staff. J. Resolution/outcome information is communicated to the complainant… I. All actions taken and follow-up performed will be documented on the complaint form, as well as reported to the management staff J. Resolution/outcome information is communicated to the complainant.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on observation, record review and interview the agency failed to ensure an update of the comprehensive assessment for 1(Patient 2) of 2 active patients after Patient 2 fell, fractured her wrist, and required surgery to repair the fracture. The agency subjected the patient to poor quality care and potential harm when the care was not revised based on the worsening patient’s condition. The patient did not obtain assistance with bathing after her fracture left her unable to use to walker. Review of Patient 2’s clinical record revealed a Comprehensive assessment completed 05/21/2024 at the start of care, and a recertification comprehensive assessment completed on 07/15/2024 and signed by the DON. A review of the entire record revealed no update to the comprehensive assessment or plan of care between 05/21/2024 and 07/15/2024. The comprehensive assessment dated 07/15/2024 did not include any information about the fractured arm. Review of Patient 2’s therapy note by PTA A documented a missed visit on 07/06/2024 due to the patient falling and breaking her left wrist. Review of Patient 2’s nurses note dated 07/11/2024 by LVN B documented the nurse conferenced with the DON regarding the client’s recent fall. Review of Patient 2’s nurses note dated 07/17/2024 by LVN B documented the nurse conferenced with the DON regarding the patient’s request for home health aide services. An interview was conducted with the DON on 07/23/2024 at 2 PM. The surveyor asked who was responsible for the update to the comprehensive assessment when the patient’s condition changed. The DON stated the RN was responsible to do the assessments and completed the Plan of Care, and the DON reviewed them. The surveyor asked why this didn’t happen. The DON stated they didn’t know about the change in condition. The surveyor made a home visit on 07/23/2024 at 3:20 PM to the residence of Patient 2. The surveyor observed Patient 2 had with a splint on her left wrist. The surveyor asked Patient 2 about her wrist. Patient 2 stated she had fallen and fractured her wrist on 07/03/24 and had surgery on it. Patient 2 stated she was unable to use her walker as the left arm was non-weight bearing at this time. Patient 2 opened the splint and showed the surveyor the incision on her left wrist. Patient 2 changed the soiled gauze dressing over the incision during the visit. Patient 2 stated she had been asking for help with bathing because she couldn’t use her left hand. Patient 2 stated she was afraid to get into the shower without assistance and Patient 2 stated her nurse had called the office two times during different weekly visits to ask for the additional help. The surveyor asked who came to see the patient after her surgery. Patient 2 stated her nurse LNV B. The surveyor asked if another nurse had come to see Patient 2 after her surgery on 07/14/24. Patient 2 stated she had a therapist come and the therapy boss, but no other nurse. The surveyor reviewed the log of visits with vital signs in the home folder. The only entries for nursing for July were for LVN B. In an interview with the DON, Administrator, and the Office Manager on 07/26/24 at 11:30 AM, the surveyor shared the findings from the record reviews and home visits. The surveyor asked why Patient 2 did not have an update to the comprehensive assessment after 07/03/24 fall. The DON stated: “I didn’t know” about the fall, fracture and surgery. The surveyor asked about the Comprehensive assessment documented on 07/15/2024 and signed by the DON. The DON stated: “I don’t remember this one.” The surveyor asked if the DON went to the patient’s home and completed the assessment dated 07/15/2024. The DON stated: “No I didn’t see her. I reviewed the assessment after talking with [LVN B].” The surveyor asked the Administrator to explain why the failure occurred. The Administrator did not respond to the question. The surveyor asked about the patient requests for help with bathing. The Office Manager stated the patient wanted home health aide services three times per week and insurance coverage was the problem. The surveyor asked why the agency did not request an OT evaluation after the patient injury and request for assistance with bathing. The DON shrugged and did not respond. The Office Manager stated she did not know, and they would take care of it. Agency policy titled “Patient Reassessment/Recertification/Post Hospital Assessment” dated 04/26/2011 read in part: “…Reassessment for Change in Clinical or Functional Status – 1. A RN/Therapist must perform the Follow-Up Comprehensive Assessment for a major decline or improvement in the patient’s clinical or functional status if the change is not considered an expected change or outcome in the Plan of Care. 2. A significant change in the clinical status (examples) – an exacerbation in the patient condition that would not have been expected with current diagnosis; - development or increase in the number of pressure ulcers; or – a deterioration or infection of wound. 3. A significant change in the functional status (examples) – significant decline in functional status due to a falls (sic) resulting from increasing weakness with addition of therapy to the plan of care when not expected in the original Plan or Care; or patient is initially independent and becomes either partially or completely dependent 4. The reassessment will be reported to the supervising nurse and patient’s physician as soon as possible but no later than 8 hours. Orders obtained from physician as necessary…”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observation, record review and interview the plan of care for the 2 (Patient 1 and 2) of 2 active patients of the agency, the plans of care failed to include a description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. The agency subjected patients to potential harm and poor-quality care. Review of Patient 1’s plan of care for the certification 06/14/24 to 08/12/24 revealed diagnoses of Type 2 Diabetes Mellitus (A condition in which the body has trouble controlling blood sugar and using it for energy), Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Generalized Anxiety Disorder (worrying constantly and can’t control it), Hypertension (high blood pressure without an identifiable cause). Review of the entire plan of care revealed no description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. In an interview with LVN A on 07/23/2024 at 1:30PM, LVN A stated she saw Patient 1 weekly on Thursdays or Fridays. LVN A stated she was working on blood sugar management with Patient 1 as her blood sugars had been high and Patient 1 didn’t have a glucometer to check her blood sugars. LVN A stated she was trying to help the patient find transportation for appointments, and Patient 1 needed to find another room to rent and would run out of minutes on her cell phone toward the end of each month. LVN A stated she had helped Patient 1 with refills of her medications and getting a glucometer. LVN A stated she was at risk of hospitalization if she didn’t control her blood sugar, and she had not had a recent hospitalization or emergency room visit that the nurse was aware of. The surveyor made a home visit on 07/23/2024 at 4:10 PM to the residence of Patient 1. The surveyor asked Patient 1 about her concerns about her health. Patient 1 stated she needed help with transportation to appointments, finding a new room to rent, and help reconnecting her cell phone. Patient 1 stated she had not been to the hospital or emergency room lately. Patient 1 stated LVN A visited her weekly and checked on her and took her blood sugar. Review of Patient 2’s plan of care for the certification 05/21/2024 to 07/19/2024 revealed Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Abnormalities of gait and mobility (deviations from normal walking and movement which can affect balance). Review of the entire plan of care revealed no description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. In an interview with the DON on 07/23/2024 at 2 PM the surveyor asked who was responsible for development of the plans of care. The DON stated the RN who did the assessments completed the Plan of Care and the DON reviewed them. The DON stated she did not check for a statement of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors because she didn’t know to. The surveyor made a home visit on 07/23/2024 at 3:20 PM to the residence of Patient 2. The surveyor observed Patient 2 had with a splint on her left wrist. The surveyor asked Patient 2 about her wrist. Patient 2 stated she had fallen and fractured her wrist on July 3 and had surgery on it. Patient 2 stated she was unable to use her walker as the left arm was non-weight bearing at this time. Patient 2 opened the splint and showed the surveyor the incision on her left wrist. Patient 2 changed the soiled gauze covering over the incision during the visit. Patient 2 stated she had been asking for help with bathing because she couldn’t use her left hand. Patient 2 stated she was afraid to get into the shower without assistance and her nurse had called the office two times during her weekly visits to ask for the additional help. In an interview with the DON, Administrator, and the Office Manager on 07.26.24 at 11:30 AM the surveyor shared the findings from the record reviews and home visits. The surveyor asked why the plans of care did not contain the required description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. The DON stated they didn’t know they needed this. The Office Manager stated they didn’t know where this information would go in the electronic medical record. The surveyor asked the Administrator if they had anything else to add to explain why the failure occurred. The Administrator stated they didn’t know they needed to do this and would correct it. Agency policy titled: Plan of Care TX.6 dated 04/04/2011 read in part: Purpose-To develop an individualized Plan of Care to ensure patient specific needs are net appropriately according to state and federal regulations…. Review of the agency policy found the policy failed to include the federal regulatory requirement for the Plan of care to include a description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors.

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 interview, the agency failed to provide each patient a visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA for 2 (Patient 1 and 2) of 2 active patients who received home visits from the surveyor. This failure placed the patients at risk of missed visits due to conflicts in scheduling other medical appointments. Review of the sample patient admission folder provided by the Office Manager on 07/23/2024 at 4 PM revealed no blank schedule forms in the packet. Review of Patient 2’s plan of care for the certification 05/21/2024 to 07/19/2024 revealed Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Abnormalities of gait and mobility (deviations from normal walking and movement which can affect balance). The surveyor made a home visit on 07/23/2024 at 3:20 PM to the residence of Patient 2. The surveyor reviewed the home folder provided by the agency and found no written schedule of services by the HHA staff. The surveyor asked Patient 2 who came to see her from the agency. Patient 2 stated LVN B and PTA A came to see her. The surveyor asked if the patient had a schedule of the frequency and disciplines coming to see her. Patient 2 stated she did not have a schedule and she would like to have a schedule so she could coordinate her and her husbands’ doctor appointments around the visits. The surveyor asked when LVN B and PTA A came to see her. The patient stated different days each week and stated they would call and say they were on the way. Review of Patient 1’s plan of care for the certification 06/14/24 to 08/12/24 revealed diagnoses of Type 2 Diabetes Mellitus (A condition in which the body has trouble controlling blood sugar and using it for energy), Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe), Generalized Anxiety Disorder (worrying constantly and can’t control it), Hypertension (high blood pressure without an identifiable cause). The surveyor made a home visit on 07/23/2024 at 4:10 PM to the residence of Patient 1. The surveyor reviewed the home folder provided by the agency and found no written schedule of services by the HHA staff. The surveyor asked Patient 1 who came to see her from the agency. Patient 1 stated LVN A came to see her. The surveyor asked if the patient had a schedule of the services with the frequency and disciplines coming to see her. Patient 2 stated she did not have a schedule and she could not call the nurse because her phone was out of minutes. The surveyor asked when LVN A came to see her. Patient 1 stated she came most weeks on different days. An interview was conducted with the DON, Administrator, and the Office Manager on 07/26/24 at 11:30 AM. The surveyor shared the findings from the review of the sample home admission packet and the ones found in Patient 1 and 2’s homes. The surveyor asked whose responsibility it was to provide the schedule of services to the patients. The DON stated it was the nurses and therapists seeing the patients. The surveyor asked why there wasn’t a schedule in the sample packet. The Office Manager said she would take care of it. The surveyor asked the Administrator why this requirement was not met. The Administrator stated they were not aware of it and would correct it. Review of the agency’s policy and procedures manual failed to find a policy with the requirements for a written schedule of service for the patients.

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 performance improvement projects for 3 (July – December 2021, 2022, 2023, and through July 26/2024.) of 3 years of the survey review period. This failure limited the agency’s ability to improve care and services to agency patients and subjected patients to substandard care due to the agency's inability to trend patterns and to implement improved services. During the entrance conference on 07/23/2024 at 11 AM the surveyor requested the agency QAPI documents for the last 3 years. A review of the QAPI documents provided by the agency on 07/26/24 revealed no Performance Improvement projects had been documented for July - December 2021, 2022, 2023, and through July 2024. No complaints were documented in the complaint log, no incidents in the incident book, no evidence of record reviews of active and discharged records, no QAPI reports, no ongoing, focused program to measure client outcomes, and no written plan of implementation. In an interview with the DON, Administrator, and the Office Manager on 07.26.24 at 11:30 AM the surveyor asked why there was no QAPI program information or committee meeting provided to the surveyor as requested. The Administrator stated: There were only 2 patients. The Office Manager asked what the surveyor was looking for. At 12:30PM the Office Manager brought the surveyor the following documents: 1. “Annual PACK meeting report County Home Health” The document read in part “The administrator discussed the operations of 2020 and explained the changes from previous year.” The document discussed the changes from 2020 and the effects on the agency from COVID 19. 2. “01/15/2023 Professional Advisory Committee Meeting – The board of directors have held a meeting on Jan 10th, 2021 to discuss the various matter…” 3. “01/15/2022 Professional Advisory Committee Meeting – The board of directors have held a meeting on Jan 10th, 2021 to discuss the various matter…” Documents 2. And 3. Were identical except for the date listed as 01/15/2023 on Document 2. and 01/15/2022. Neither document contained evidence of an ongoing QAPI program. 4. “01/15/2022 Professional Advisory Committee Meeting – 01/01/2021 thru 12/31/2021 -The board of directors have held a meeting on Jan 10th, 2021 to discuss the various matter…” The rest of document 4 was identical to Document 2 and 3. None of the documents contained evidence of an ongoing QAPI program. 5. Document 5 listed the agency’s name and address and phone number, date 01/16/2023 and read in part “The Administrative Committee have conducted a meeting and Attended a Webinar and discussed on the matters to improve our Quality Care and Learning New Changes… Get ready for Joint Commission survey…” 6. Document 6 listed another agency’s name, and the same address and phone number. Document 6 was identical to Document 5. In an interview with the DON, Administrator, and the Office Manager on 07.26.24 at 1:00 PM the surveyor asked about documents 1-4 containing dates and information regarding January 2020. There was no response from the DON. Administrator and the Office Manager. The surveyor asked if the agency was getting ready for Joint Commission survey. The Administrator stated that was for another home health agency. The surveyor asked who was responsible for the QAPI program and the Performance Improvement Projects. The Administrator stated he was and “the agency had only 2 patients.” The agency did not provide additional documents or evidence of a Performance Improvement Projects by the end of the survey. Review of the agency policy titled: “QAPI. 1 Quality Assessment Performance Improvement Plan Revised date: 032710” read in part: PURPOSE - To develop a Quality Assessment Performance Improvement Plan (QAPI), developed by leaders and implemented by the QAPI/Utilization Review (UR) committee, which captures significant outcomes essential to safe and quality care. POLICY - Agency leaders will develop a plan that sets priorities for data collection and is reviewed and updated or revised at least once within the calendar year, or more often if needed, by the QAPI/UR Committee. Agency will strive to improve operational and patient health outcomes by implementing a performance improvement plan that incorporates the following essential processes: • Designing processes; • Monitoring performance through data collection; • Analyzing current performance; and • Improving and sustaining improved performance over time. Agency will focus primarily on its processes and/or system performances rather than an individual's performance yet will recognize the importance of the competence of its staff. Performance improvement priorities identified by leaders will be identified through the collection of data for analysis of Agency services with a system that measures significant outcomes. Review of the agency policy titled: “QAPI.5 Performance Improvement Process: Improved Performance revised date 050407” read in part: “… Policy Agency leaders/QAPI committee will be responsible for setting the priorities for improvement activities based on Agency functions, the defined measurement factors, the resources required to facilitate the improvement …” Review of the agency policy and procedures manual found no specific policy addressing the requirements for Performance improvement projects.

Purpose of Visit: Recertification survey Entrance Date: 06/22/2021 An entrance conference was conducted with the agency Adm, Alt Adm and other administrative staff at 11:15 a.m. Employee A was informed that the purpose of the survey was for a 36-month recertification survey. L&C Census: 1 Exit Date: 06/28/2021 An exit conference was conducted at 3:00 p.m. with the agency Adm, Alt Adm and other administrative staff. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional documentation. Additional documentation was not provided for EP. The agency was informed that if violations were cited, the agency would receive the Statement of deficiencies within 10 business days post exit. Written instructions were provided for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of deficiencies. Abbreviations: L & C- Licensed and Certified EP- Emergency Preparedness

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: The deficiency was previously cited at E 006 during survey dated 11/27/2017. Based on record review and interview, the agency failed to have a written emergency preparedness and response plan that was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach that included strategies for addressing emergency events identified in the risk assessment. The risk assessment was not updated to include the Novel Coronavirus of 2019 pandemic and did not include strategies for addressing emergency events related to the pandemic. The failure could have caused the agency to not be properly prepared for a COVID-19 outbreak among the agency's patients and staff. FINDINGS INCLUDED: During the entrance conference at 11:15 a.m. on 06/22/2021, the Adm self-identified as the disaster coordinator. The Adm identified the supervising nurse, RN B as the alternate disaster coordinator. Review of the agency's EP binder revealed the following: 1. A "2018" unsigned document tilted. "Hazard Vulnerability Assessment Tool." The assessment tool included a potential disaster titled "Epidemic/Pandemic Disease. Epidemic/Pandemic was given an "unlikely" probability level and a "low disruption" vulnerability level. 2. An undated and unsigned document tilted. "Hazard Vulnerability Assessment Tool." The assessment tool included a potential disaster titled "Epidemic/Pandemic Disease. Epidemic/Pandemic was given an "unlikely" probability level and a "low disruption" vulnerability level. The binder did not contain any further documents that showed the agency had updated the EP plan and risk assessment to include the COVID-19 pandemic in its EP and response plan. In an interview on 06/28/2021 at 1:15 p.m., with the Adm, the surveyor discussed the above findings and asked why the agency's risk assessment and agency policy was not updated to include the COVID-19 pandemic. The Adm replied, "That's a good question. The policy was prepared before COVID-19 and I did not update the policy." Record review of agency policy titled "EMERGENCY PREPAREDNESS" revised 080111 read in part: " ...POLICY ...Agency will create a Hazard Threat Analysis (located in Emergency preparedness Response and Plan Manual) to identify the potential disasters from natural and man-made causes mostly likely to occur in agency's service area. These threats that may potentially create a risk include, but not limited to: tornados, flash floods, chemical spills or incidents, severe ice storms/blizzards, terrorism, lightening, nuclear power plant incidents, hurricane or tsunami and wild fires...Agency will maintain documentation of compliance with the required elements and agency policies in the Emergency Preparedness Response and Plan Manual ..." The policy was not updated to include the Novel Coronavirus of 2019 pandemic and did not include strategies for addressing emergency events related to the pandemic.

Purpose of Visit: Recertification survey Entrance Date: 06/22/2021 An entrance conference was conducted with the agency Adm, Alt Adm and other administrative staff at 11:15 a.m. The Adm was informed that the purpose of the survey was for a 36-month recertification survey. L&C Census: 1 Exit Date: 06/28/2021 An exit conference was conducted at 3:00 p.m. with the Adm, Alt Adm and other administrative staff. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional documentation. Additional documentation was provided, agency QAPI documents. The agency was informed that if deficiencies were cited, the agency would receive the Statement of Deficiencies within 10 business days post exit. Written instructions were provided for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of deficiencies. Second Exit date 07/01/2021 was conducted at 10:50 a.m. with the Adm, Alt Adm, DON and the Med Coder. The surveyor discussed the reason for the second exit was for potential non-compliance of the of 484.45(a): Encoding and Transmitting OASIS. Met conditions of participation. Abbreviations: ADM - Administrator Alt Adm - Alternate Administrator DON - Direction of Nurses (Supervising Nurse) ADON - Alternate Director of Nurses OT - Occupational Therapist LVN - Licensed Vocational Nurse Med Coder -Medical Coder Billing Mgr. - Billing Manager PTA - Physical Therapy Assistant Intake Coor - Intake Coordinator L & C- Licensed and Certified NOMNC- Notice of Medicare Non-Coverage POC- Plan of Care SOC- Start of Care HH- Home Health HHA's- Home Health Agencies PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement QA/PI/UR- Quality Assessment/Performance Improvement/Utilization Review OASIS -outcome and assessment information set Moo90-Date OASIS Assessment is completed. SN- Skilled Nursing Registered Nurse (RN) Physical Therapist (PT) CMS- Center for Medicare and Medicaid Services Health and Human Services Commission (HHSC) TULIP- Texas Unified Licensure Information Portal Department of Aging and Disability (DADS) COVID-19- Novel Coronavirus Disease 2019 QIO-Quality Improvement Organization

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: This deficiency was previously cited at G 323 during survey dated 11/27/2017. Based on record review and interview, the agency failed to transmit completed OASIS assessments to CMS OASIS contractor, within 30 days of completing the OASIS assessment of the beneficiary (patient) in: 1. Seven of Seven randomly selected OASIS assessments submitted in 2018. 2. Eight of Eight randomly selected OASIS assessments submitted in 2019. The failure could have prevented the agency's patient data from being made available to CMS for analysis in order to identify agency performance levels in the provision of patient care. FINDINGS INCLUDED: On 06/28/2021 during an exit interview, the agency submitted OASIS Final Validations reports for the years 2018 and 2019 to the surveyor for review. The surveyor reviewed the provided OASIS documents on 06/29/2021, post exit. The documents revealed that the agency had not submitted the completed OASIS assessments to CMS OASIS contractor within 30 days of completing the assessment. The following OASIS Final Validation reports showed that the agency had not submitted the OASIS assessments within 30 days: 1. 2018 OASIS assessments dated 02/07/2018; 04/04/2018; 04/27/2018; 06/22/2018; 07/24/2018; 07/24/2018 and 11/08/2018 had the message "WARNING Record Submitted Late: The submission date is more than 30 days after Moo90 on this new record." 2. 2019 OASIS assessments dated 01/15/2019; 02/27/2019; 03/13/2019; 04/14/2019; 06/04/2019; 06/04/2019; 12/05/2019 and 12/05/2019 had the message "WARNING Record Submitted Late: The submission date is more than 30 days after Moo90 on this new record." A second exit was conducted on 07/01/2021 at approximately 10:30 a.m. with the administrative staff (the Adm, Alt Adm, DON and Med Coder). The surveyor discussed the above findings and asked why the agency had not transmitted the completed OASIS assessments to CMS OASIS contractor, within 30 days of completing the OASIS assessment of the beneficiary (patient). The Med Coder replied, "Sometimes the nurses submit it [the OASIS] late."

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 seven of seven inactive patient records reviewed. The agency failed to provide patients # 4 through 10 with the Centers for Medicare and Medicaid form titled Notice of Medicare Non-Coverage. The failure could place the patients at risk of harm due to inadequate or inappropriate continuity of care in the patients' post-discharge needs and could prevent the patients from exercising the right to appeal the discharge decision, if desired. FINDINGS INCLUDED: Clinical Record # 4: Record review 06/25/2021. Record review of the electronic clinical record for Patient # 4 revealed a POC for the certification period of 05/25/2020 to 07/23/2020 with a SOC date of 05/25/2020 and signed by the DON. The POC was dated 05/25/2020. Patient # 4's record included a discharge summary dated 07/09/2020 and showed a discharge date of 07/09/2020. On 06/28/2021 at approximately 11:15 a.m., the surveyor requested any hard copy clinical records for Patient # 4. The Intake Coor stated that all clinical records for Patient # 4 were uploaded into the electronic record. Patient # 4's record 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, 07/09/2020. The record did not include a written NOMNC. Clinical Record # 5: Record review 06/25/2021. Record review of the electronic clinical record for Patient # 5 revealed a POC for the certification period of 06/03/2020 to 08/01/2020 with a SOC date of 06/03/2020 and signed by PT, O. The POC was dated 06/05/2020. Patient # 5's record included a PT discharge summary dated 07/09/2020. On 06/28/2021 at approximately 11:15 a.m., the surveyor requested any hard copy clinical records for Patient # 5. The Intake Coor stated that all clinical records for Patient # 5 were uploaded into the electronic record. Patient # 5's record 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, 07/09/2020. The record did not include a written NOMNC. Clinical Record # 6: Record review 06/25/2021. Record review of the electronic clinical record for Patient # 6 revealed a POC for the certification period of 12/29/2019 to 02/26/2020 with a SOC date of 03/09/2018 and signed by the ADON. The POC was dated 12/27/2019. Patient # 6's record included a discharge OASIS dated 02/26/2020. On 06/28/2021 at approximately 11:15 a.m., the surveyor requested any hard copy clinical records for Patient # 6. The Intake Coor stated that all clinical records for Patient # 6 were uploaded into the electronic record. Patient # 6's record 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, 02/26/2020. The record did not include a written NOMNC. Clinical Record # 7: Record review 06/25/2021. Record review of the electronic clinical record for Patient # 7 revealed a POC for the certification period of 04/14/2018 to 06/12/2018 with a SOC date of 08/28/2015 and signed by RN P. The POC was dated 04/14/2018. Patient # 7's record included a discharge order dated 06/12/2018. On 06/28/2021 at approximately 11:15 a.m., the surveyor requested any hard copy clinical records for Patient # 7. The Intake Coor stated that all clinical records for Patient # 7 were uploaded into the electronic record. Patient # 7's record 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, 06/12/2018. The record did not include a written NOMNC. Clinical Record # 8: Record review 06/25/2021. Record review of the electronic clinical record for Patient # 8 revealed a POC for the certification period of 04/19/2018 to 06/17/2018 with a SOC date of 04/24/2017 and signed by RN P. The POC was dated 04/19/2018. Patient # 8's record included a discharge OASIS dated 06/14/2018. On 06/28/2021 at approximately 11:15 a.m., the surveyor requested any hard copy clinical records for Patient # 8. The Intake Coor stated that all clinical records for Patient # 8 were uploaded into the electronic record. Patient # 8's record 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, 06/14/2018. The record did not include a written NOMNC. Clinical Record # 9: Record review 06/25/2021. Record review of the electronic clinical record for Patient # 9 revealed a POC for the certification period of 01/11/2018 to 03/11/2018 with a SOC date of 11/23/2015 and signed by RN P. The POC was dated 01/11/2018. Patient # 9's record included a PT discharge dated 03/08/2018. On 06/28/2021 at approximately 11:15 a.m., the surveyor requested any hard copy clinical records for Patient # 9. The Intake Coor stated that all clinical records for Patient # 9 were uploaded into the electronic record. Patient # 9's record 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, 03/08/2018. The record did not include a written NOMNC. Clinical Record # 10: Record review 06/25/2021. Record review of the electronic clinical record for Patient # 10 revealed a POC for the certification period of 06/09/2019 to 08/07/2019 with a SOC date of 08/18/2017 and signed by RN G. The POC was dated 06/09/2019. Patient # 10's record included a discharge order dated 07/31/2019. On 06/28/2021 at approximately 11:15 a.m., the surveyor requested any hard copy clinical records for Patient # 10. The Intake Coor stated that all clinical records for Patient # 10 were uploaded into the electronic record. Patient # 10's record 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, 07/31/2019. The record did not include a written NOMNC. In an interview on 06/28/2021 at approximately 1:45 p.m. with the Adm and the DON, the surveyor discussed the above findings and asked why the agency had not provided 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 # 4 through 10. The Adm replied, "I was not aware of that." Review of agency policy titled "PATIENT DISCHARGE" revised 031110 read in part: "POLICY...Agency will deliver the ...CMS notice NOMNC ... to the patient (or authorized representative), no less than two days prior to the day of anticipated discharge, or as soon as the provider determines coverage will end ..."

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on record review, observation at home visits and interviews, the agency failed ensure the patients' right to be advised of the names, addresses, and telephone numbers of federally-funded and state-funded entities that service the area where the patient resided in three (Patients # 1, 2 and 3) of three patient home visits, with review and observation of the patient's admission folder. The failure did not conform to the patients' right to be advised regarding the entities contact information in the event such information was needed by the patient. This failure could result in the patients' missed opportunities to obtain and access extra services from the community that were not provided by the agency. FINDINGS INCLUDED: On 06/22/2021 the surveyor reviewed the agency's sample Medicare admission packet. The sample packet included a document titled "Patient Rights." The document read in part: " ...Federally and State Funded Resources." The names of the following agencies were listed: Agency on Aging Center for Independent Living Protection and Advocacy Agency, Aging and Disability Resource Center; and Quality Improvement Organization. The contact information that was listed for the agencies were not for the service area where the agency's patients resided. Patient #1: Review of the clinical record for Patient # 1 revealed a POC with a SOC date of 05/26/2021, with the primary diagnosis of polyneuropathy. The POC for certification period 05/26/2021 to 07/24/2021 was electronically signed by PT H on 05/26/2021. During a home visit conducted on 06/24/2021 at approximately 2:30 p.m., the surveyor observed and reviewed Patient #1's home admission folder. The home folder did not include the names, addresses, and telephone numbers of the following federally-funded and state-funded entities that served the area where the patient resided: Agency on Aging; Center for Independent Living; Protection and Advocacy Agency; Aging and Disability Resource Center and QIO. Patient #2: Review of the clinical record for Patient # 2 revealed a POC with a SOC date of 06/04/2021, with the primary diagnosis of chronic systolic congestive heart failure. The POC for certification period 06/04/2021 to 08/02/2021 was electronically signed by RN G on 06/04/2021. During a home visit conducted on 06/24/2021 at approximately 4:00 p.m., the surveyor observed and reviewed Patient #2's home admission folder. The home folder did not include the names, addresses, and telephone numbers of the following federally-funded and state-funded entities that served the area where the patient resided: Agency on Aging; Center for Independent Living; Protection and Advocacy Agency; Aging and Disability Resource Center and QIO. Patient #3: Review of the clinical record for Patient # 3 revealed a POC with a SOC date of 06/12/2020, with the primary diagnosis of late onset cerebellar ataxia. The POC for certification period 04/08/2021 to 06/06/2021 was electronically signed by RN C on 04/08/2021. During a home visit conducted on 06/24/2021 at approximately 1:20 p.m., the surveyor observed and reviewed Patient #3's home admission folder. The home folder did not include the names, addresses, and telephone numbers of the following federally-funded and state-funded entities that served the area where the patient resided: Agency on Aging; Center for Independent Living; Protection and Advocacy Agency; Aging and Disability Resource Center and QIO. During an interview on 06/28/2021 at approximately 12:30 p.m., the surveyor discussed the above findings with the Adm. The surveyor asked why the sample admission packet and the home folders for Patients # 1, 2 and 3 did not include the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that served the area where the patients resided: Agency on Aging; Center for Independent Living; Protection and Advocacy Agency; Aging and Disability Resource Center and Quality Improvement Organization. The Adm replied, "We did not know."

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, in one of one agency QAPI program, the agency failed to conduct PIP(s) for the calendar years 2018, 2019 and 2020 that reflected the scope, complexity and past performance of the agency's services and operations. The failure could place the agency at risk of not improving and providing quality care and services to the agency's patients. FINDINGS INCLUDED: During the entrance conference on 06/22/2021 at approximately 11:40 a.m. the surveyor requested all agency QAPI/documents/reports/binders. Record review of the agency's QAPI records did not reveal any reports, reviews or documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements, for the years 2018, 2019 and 2020. During an interview on 06/22/2021 at approximately 3:00 p.m., with the Adm, the Med Coder, and the Intake Coor, the surveyor asked if the agency had provided all records from the "Home Care Request" list that was provided at the entrance conference. The list included the request for QAPI records. Both the Med Coder and the Intake Coor replied, "Yes." The Med Coder and the Intake Coor were designated by the Adm as agency contacts for records request. During an interview on 06/28/2021 at 11:45 a.m., with Adm, the Alt Adm, the DON, and the Med Coder, the surveyor discussed the above findings. The surveyor asked why the agency had not ensured that the agency's QAPI program was implemented and maintained for the years 2018, 2019 and 2020 per federal regulatory requirements. The Adm replied, "We only have three patients." The DON replied, "It's in the computer." The surveyor asked who was responsible for the QAPI program. The Adm replied, "[The Med Coder]." The DON stated that RN C was responsible for review of the agency's nurses' documentation and compliance. The surveyor asked the Med Coder, if she, the Med Coder, had access to the QAPI documentation in the computer. The Med Coder replied, "Yes." The surveyor requested the documents be printed. The documents were printed and provided to the surveyor during the exit interview. The exit conference was conducted on 06/28/2021 at 3:00 p.m. The surveyor reviewed the provided QAPI documents on 06/29/2021. The documents did not contain any reports, reviews or documentation that indicated the agency had conducted PIPs, for the years 2018, 2019 and 2020. A second exit was conducted on 07/01/2021 at approximately 10:30 a.m. with the administrative staff (the Adm, the Alt adm, the DON and the Med Coder). The surveyor asked why the agency had not conducted PIPs for 2018, 2019 and 2020, in accordance with federal regulatory requirements? The Billing Mgr. replied, "Short staffed. The former office manager left, and no-one followed up." The Med. Coder replied, "Too may different tasks and [it] was overlooked." Review of agency policy titled "PERFORMANCE IMPROVEMENT PROCESS QAPI.5" revised 050407 was not updated to include the federal regulatory requirements for PIPs beginning July 13, 2018.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interviews, the agency's governing body failed to ensure that, in one of one QAPI program, an ongoing program for quality improvement and patient safety was implemented and maintained. The agency failed to address priorities for improved quality of care and patient safety and ensure that: all improvement actions were evaluated for effectiveness; clear expectations for patient safety were established, implemented, and maintained for the years 2018, 2019 and 2020. The failure could have placed the agency's Patients at risk of substandard care from unidentified and uncorrected problems and/or weaknesses with patient care. FINDINGS INCLUDED: During the entrance conference on 06/22/2021 at approximately 11:40 a.m. the surveyor requested all agency QAPI/documents/reports/binders. Billing manager, Employee L provided QAPI binders for 2018 and 2019 at 1:35 p.m. Review of the QAPI binders revealed the binders contained the following blank forms: 1. Monthly facility incident report. 2. Patient/Employee Incident report 3. Weekly infection control plan. 4. Infection control log. 5. Document to report antibiotic after admission to HH. 6. Complaint log. 7. Patient/Employee occurrence/Incident report. 8. Safety/Fall prevention patient self-questionnaire. 9. Hospital transfer log. 10. Abuse, neglect and exploitation log. 11. Chart audits completed five (5) each month. 12. QA/PI/UR record review. On 06/22/2021 at 2:28 p.m. the surveyor requested all QAPI and infection control records for 2020. The binder was provided by billing manager, Employee L. Review of the 2020 QAPI binder revealed the above listed blank forms. The binders did contain two completed infection control patient reports for Client # 11. The binder did not contain any reports, reviews or documentation that indicated the agency had maintained a QAPI program that included the federal regulatory requirements for the years 2018, 2019 and 2020. During an interview on 06/22/2021 at approximately 3:00 p.m., with the Adm, the Med Coder, and the Intake Coor, the surveyor asked if the agency had provided all records from the "Home Care Request" list that was provided at the entrance conference. The list included the request for QAPI records. Both the Med Coder and the Intake Coor replied, "Yes." The Med Coder and the Intake Coor were designated by the Adm as agency contacts for records request. During an interview on 06/28/2021 at 11:45 a.m., with the Adm, Alt Adm, DON and the Med Coder, the surveyor discussed the above findings. The surveyor asked why the agency had not ensured that the agency's QAPI program was implemented and maintained for the years 2018, 2019 and 2020 per federal regulatory requirements. The administrator, Employee A replied, "We only have three patients." The DON replied, "It's in the computer." The surveyor asked who was responsible for the QAPI program. The Adm replied, "[The Med Coder]." The DON stated that she, the DON was responsible for review of the agency's nurses' documentation and compliance. The surveyor asked the Med Coder if she had access to the QAPI documentation in the computer. The Med Coder replied, "Yes." The documents were printed and provided to the surveyor. The documents did not contain any reports, reviews or documentation that indicated the agency had maintained a QAPI program that included the regulatory requirements, for the years 2018, 2019 and 2020.

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, in one of one infection control program, the agency failed to enforce a written policy to review and revise all aspects of its infection control program annually for the years 2018, 2019 and 2020. The failure could have placed the agency's patients at risk of contracting and spreading infectious and communicable diseases. FINDINGS INCLUDED: During the entrance conference on 06/22/2021 at approximately 11:40 a.m. the surveyor requested all agency infection control logs/documents/reports/binders. Billing Mgr. provided QAPI binders for 2018 and 2019 at 1:35 p.m. and stated, "I think infection control in here." Review of the QAPI binders revealed blank infection control logs and forms. On 06/22/2021 at 2:28 p.m. the surveyor requested all QAPI and infection control records for 2020. The binder was provided by Billing Mgr. Review of the QAPI binders revealed blank infection control logs and forms. The binders did contain two completed infection control patient reports for Client # 11. Review of the binders did not show that the agency had reviewed and revised all aspects of the agency's infection control program annually for the years 2018, 2019 and 2020. The binders did not show that the agency had updated its infection control program, policy and procedure, in 2020, to prevent the spread of COVID-19 among its clients and staff. During an interview on 06/28/2021 at 1:25 p.m. with the Adm and the DON, the surveyor discussed the above findings and asked why the infection control program and policy had not been reviewed and revised/updated per agency policy, specifically to include the prevention and spread of COVID-19 in 2020. The Adm replied, "We overlooked it and we are short staffed." The supervising nurse, RN C replied, "We are short staffed." Agency policy titled "INFECTION CONTROL PROGRAM" revised 030310 read in part: "POLICY ...The Infection Control Program will include ...E. All aspects of the program will be reviewed and revised annually ..."