Every finding on record at All Care Home Health

This Statement of Deficiencies was generated as a result of an Emergency Preparedness survey conducted at your agency from March 12, 2024 through March 14, 2024, in accordance with 42 Code of Federal Regulations (CFR) and the State Operations Manual (SOM), Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types. Findings include:

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based upon interview, employee file and document review, the Agency failed to maintain documentation direct care staff had receiving training on the agency's emergency preparedness plan for 10 of 10 employee files reviewed. This deficient practice has the potential to affect the direct care staffs’ ability to assist the Agency in continuing to provide patient care and address safety needs of the patients, and staff in protecting themselves in the event of an emergency. Findings include: A review of ten employee files revealed an annual Emergency Preparedness Checklist. The directions indicated to check the box next to each subject addressed in the emergency preparedness training. The subjects included the following: - Emergency preparedness policies and procedures. - Top potential emergencies in the agency’s geographic service area. - Agency Emergency Preparedness Plan. - My requirements for annual emergency preparedness training. - My participation in periodic emergency preparedness exercises. - My role and responsibilities in the event of an emergency. - Emergency chain of command. - Staff safety. - Requirements for dress code, identification card/badge/name tag, professional license, any local state credentials needed to move around a restricted area. - How to obtain supplies (e.g., forms, office, medical, patient). - Agency’s communication plan. - Process for an emergency occurring after office hours (e.g., in office, on duty, with a patient). - Process for an emergency after office hours (e.g., on duty, with a patient, at home). - Where to report to in an event of an emergency (e.g., in office, alternate location) if directed. - Alternate documentation process in the event electronic record (patient, employee, scheduling, payroll, and billing) is inaccessible. - The patients individual Patient/Client emergency plan form. - Importance of having my own family emergency plan. - Vehicle emergency preparation (gas, maps, ER Kit, flares). The checklist indicated the staff members verified they received the above Emergency Preparedness Training and understood the information covered. This area was signed and dated by the staff member. The checklist documented, "I have reviewed the above subjects with the employee and confirm this employee demonstrated knowledge of the agency’s Emergency Preparedness Plan, policies, and procedures". This area was signed and dated by the Assistant Administrator. On 3/12/2024 in the afternoon, the Administrator indicated initial and annual training for current staff was completed; however, there was no documentation provided to show evidence of annual or biennial (once every two years) training. The Administrator indicated everything for emergency preparedness was in the binder. No further documentation related to emergency preparedness training was provided. The Administrator acknowledged the annual training had not been documented as completed. On 03/13/2024 at approximately 2:59 PM, the Medical Records staff indicated receiving training on emergency preparedness training when starting with the Agency in September 2022. The Administrator went over the EP policies at the time of hire. The medical records staff did not recall receiving any EP training since September 2022. On 03/14/2024 at 10:56 AM, the Assistant Administrator indicated being responsible for hiring personnel and onboarding training regarding agency polices except for the emergency preparedness. The Administrator handled all the emergency preparedness training. The Assistant Administrator explained the annual training was done at the beginning of the year. The Assistant Administrator showed an employee file to include an annual Emergency Preparedness Checklist. On 03/12/2023 at approximately 4:01 PM, the Administrator indicated emergency preparedness training was provided to staff upon hire and annually, but nothing was documented. The Administrator verbalized, “we could do better on the training part.” On 03/14/2024 at 1:44 PM, the Assistant Administrator indicated the checklist was given to the staff to check off and then signed. The Assistance Administrator acknowledged they had not reviewed the emergency preparedness with the staff. The Agency's policy entitled Emergency Operations Plan and Policies documented preparation activities for an emergency included staff orientation and annual training. The Agency's policy entitled Emergency Operations Plan (EOP) Training Program documented the Agency will provide emergency preparedness training at least annually and maintain documentation of the training.

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 document review and interview, the Agency failed to evaluate the response to and maintain documentation of emergency drills to include the lessons learned following emergency drills and identify concerns to make improvements to their emergency plan; and conduct and maintain documentation of an annual tabletop exercise. This deficient practice has the potential to impact the Agency’s ability to address the immediate and short-term effects of an emergency, and provider's ability to continue providing care and services during an emergency. Findings include: A review of the Agency's Emergency Preparedness (EP) Binder revealed an annual emergency preparedness drill for an Active Shooter was conducted on March 3, 2022 and for a Heat Emergency on May 10, 2023. The EP drills lacked documented evidence the Agency evaluated and documented a response to the emergency drills, identified deficiencies and opportunities for improvement as a result of the drills for the Agency's EP plan. On 03/12/2023 at approximately 4:01 PM, the Administrator acknowledged no post drill evaluations were conducted to identify concerns or the need for improvements to the agency's emergency plan. On 03/14/2024 at approximately 1:10 PM, the Administrator indicated discussions took place regarding emergency preparedness. The Administrator was unfamiliar with the description of a tabletop exercise. The Agency lacked documented evidence tabletop exercises had been completed. The Agency's policy entitled Testing Program for Emergency Operations Plan (undated), documented Leaders, managers and staff will evaluate each emergency response exercise and all responses to emergencies. Evaluation will include the identification of deficiencies and opportunities for improvement. The plan will be modified based on the evaluation of deficiencies and opportunities for improvement. Future planned exercises will reflect modifications and any interim measures described in the plan.

This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey conducted at your agency from March 12, 2024 through March 14, 2024 , in accordance with 42 CFR (Code of Federal Regulations) Part 484 - Home Health Services. The census on the first day of the survey was 39 patients. Eight clinical records were reviewed. Two home visits were conducted. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure confidentiality of a patient record for one unsampled patient. Findings include: Patient #5 On 9/19/2023, the agency admitted Patient #5 with adjustment/fitting of urinary device. On 3/13/2024 at 12:28 PM while reviewing the electronic clinical record, two documents were identified of an unsampled patient uploaded into Patient #5's clinical record. One was entitled resumption of care information, dated 2/24/2024. The other document was hospital discharge paperwork faxed, dated 2/5/2024. The Assistant Administrator verified the findings.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to identify oxygen as a medication on a medication profile for 1 of 8 patients (Patient #5). Findings include: On 9/19/2023, the agency admitted and certified Patient #5 with supplemental oxygen dependence to 11/17/2023. The agency recertified Patient #5 with supplemental oxygen dependence from 11/18/2023 to 1/16/2024 and again from 1/17/2024 to 3/16/2024. The medication profile lacked documented evidence oxygen was listed as a medication for all three care episodes. On 3/13/2024 in the afternoon, the Director of Nursing verified the findings.

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 interview and record review, the agency failed to ensure the Outcome and Assessment Information Set (OASIS/a comprehensive patient assessment) was completed within the required time frame for 1 of 8 sampled patients (Patient 4). The deficient practice had the potential for failure to identify the patient’s clinical status, functional status, and service needs in real time. Findings include: Patient 4 (P4) P4 was admitted on 02/12/2024, with diagnoses including chronic obstructive pulmonary disease and bacterial pneumonia. The physician’s order dated 03/02/2024, documented hold home health services. Patient was admitted to the hospital due to urinary tract infection. On 03/13/2024 in the morning, a review of P4’s electronic health record revealed the OASIS dated 03/02/2024 was “In Progress”. The Director of Nursing (DON) confirmed the patient’s transfer OASIS had not been completed. The DON would verify with the nurse on why P4’s transfer OASIS had not been completed. On 03/13/2024 at 1:57 PM, the DON provided a copy of P4’s OASIS E Transfer without Discharge Assessment dated 03/02/2024. The Document History of the transfer OASIS revealed the following status of the OASIS: - 03/10/2024 at 8:16 PM, In Progress - 03/13/2024 at 11:42 AM, In Progress - 03/13/2024 at 11:45 AM, Submitted - 03/13/2024 at 11:47 AM, In Quality Assurance (QA) - 03/13/2024 at 11:48 AM, Approved The DON acknowledged P4’s transfer OASIS should have been completed within five days from 03/02/2024 or on 03/07/2024.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review, interview and document review, the Agency failed to ensure the plan of care for 7 of 8 patients was signed and dated within thirty working days by the attending physician. (Patient #s 5,1,2,6,7,3,4 and 8) This failure has the potential to affect the efforts to effectively coordinate and support the objectives outlined in the patients’ plan of care. Findings include: The Agency's policy entitled Physician’s Plan of Care/Change Orders (undated) documented the Plan of Care shall be developed within fifteen (15) days of the assessment and shall be signed and dated within thirty (30) working days by the attending physician. Patient 3 (P3) P3 was admitted on 02/09/2023 and discharged on 04/11/2023, with diagnoses including candidiasis of skin and nail and liver cancer. P3’s Home Health Certification and Plan of Care document for the certification period 04/10/2023 to 06/08/2023, indicated the attending physician signed the document on 07/28/2023. Patient 4 (P4) P4 was admitted on 02/12/2024, with diagnoses including chronic obstructive pulmonary disease and bacterial pneumonia. P4’s Home Health Certification and Plan of Care document for the certification period 02/12/2024 to 04/11/2024 lacked the signature of the attending physician. Patient 8 (P8) P8 was admitted on 01/04/2024, with a diagnosis of pressure ulcer on buttocks. P8’s Home Health Certification and Plan of Care document for the certification period 01/04/2024 to 03/03/2024 lacked the signature of the attending physician. The Home Health Certification and Plan of Care document contained the patients’ diagnoses, physician’s orders for discipline and treatments with frequency of visits and duration, and medication orders. On 03/13/2024 at 2:24 PM, the Director of Nursing (DON) explained the Home Health Certification and Plan of Care should have been signed by the attending physician within 30 days from a patient’s start of care or start of a certification period. The DON confirmed P3’s Home Health Certification and Plan of Care was signed more than 30 days, and P4 and P8’s Home Health Certification and Plan of Care had not been signed yet by the attending physician. On 03/14/2024 at 12:05 PM, the DON clarified the Home Health Certification and Plan of Care should have been signed by the attending physician within 30 calendar days from a patient’s start of care or start of a certification period. The DON revealed the agency had not received the signed Home Health Certification and Plan of Care for P4 which had a due date of 03/13/2024. Patient 1 (P1) P1 was admitted on 10/15/2023 and discharged on 11/4/2023, with diagnoses including Alzheimer’s dementia, hypertension, and urinary tract infection (UTI). P1's Home Health Certification and Plan of Care for certification period 10/15/2023 – 12/03/2023 was signed by the attending physician on 01/23/2024. Patient 2 (P2) P2 was admitted on 03/16/2023 and discharged on 05/12/2023, diagnoses including acute tubulo-interstitial nephritis, sepsis, and urinary tract infection. P2’s Home Health Certification and Plan of Care for certification period 03/16/2024 – 05/14/2024 was signed by the attending physician on 06/26/2023. Patient 7 (P7) P7 was admitted on 01/31/2024 with diagnoses including mild Lewy body dementia. P7’s Home Health Certification and Plan of Care for certification period 01/31/2024 – 03/30/2024 was not signed by the attending physician. Patient #5 On 9/19/2023, the agency admitted and certified Patient #5 for three consecutive care episodes as follows: 9/19/2023 to 11/17/2023. 11/18/2023 to 1/16/2024. 1/17/2024 to 3/16/2024. The plans of care for the first two care episodes were signed 1/25/2024 and 1/29/2024 respectively. The plan of care for the third care episode was not signed. On 3/14/2024 in the afternoon, the Director of Nursing and Assistant Administrator indicated the agency had 30 days for the physician to sign plans of care. The Plan of Care policy provided revealed the plan of care was developed within 15 days of the assessment and signed and dated within 30 working days by the physician.

Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner's issuing orders for the HHA plan of care. This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure missed visits were communicated to physicians for 1 of 8 patients (Patient #5). Findings include: On 9/19/2023, the agency admitted Patient #5 with encounter for adjustment/fitting of urinary device. The certification of the care episode was 9/19/2023 to 11/17/2023. On 10/10/2023, a physician ordered weekly skilled nursing visits for 6 weeks. On 10/27/2023, a registered nurse documented a missed skilled nursing visit. On 11/03/2023, a registered nurse documented a missed skilled nursing visit. The clinical record lacked documented evidence of a physician signature. On 3/14/2024 in the afternoon, the Director of Nursing verified the findings. The Missed Visit and PRN Visit Documentation policy provided revealed, if no rescheduling within the physician prescribed frequency could be accomplished, then the missed visit needed to be documented in the clinical record by completion of the Patient Missed Visit form which was sent to the physician for signature confirming acknowledgement of the missed visit.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the agency failed to ensure it submitted a 60 day clinical summary to a physician for 1 of 8 patients (Patient #5). Findings include: On 9/19/2023, the agency admitted Patient #5 with adjustment/fitting of urinary device. The certification of the care episode was 9/19/2023 to 11/17/2023. The clinical record lacked documented evidence of a 60 day summary. On 3/14/2023 at 12:05 PM, the Director of Nursing verified the finding. The Physician's Summary/Progress Report policy provided, revealed a summary regarding the patient's progress was prepared by the case manager for all applicable disciplines participating in the patient's care and was submitted to the physician at least every 60 days. A copy of the summary was maintained in the clinical record.

Medical social services supervised by MSW CFR(s): 484.75(c)(3) Medical social services are provided under the supervision of a social worker that meets the requirements of §484.115(m). This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure a medical social worker (MSW) was hired or contracted to provide the social services needs of the patients. The deficient practice had the potential for the patients not receiving the required social services per the physician’s orders. Findings include: The agency’s brochure (leaflet/booklet) used in marketing, contained the information about the services being offered by the agency to its clients/patients, which included medical social workers. The brochure documented MSW would be available to assist patients and their family to cope with the personal and emotional impact of illness and/or disability and to research any financial resources and/or community assistance which might be available to them. The agency’s Home Health Admission Booklet provided to the patients and maintained in the patients’ home, documented the agency’s services such as medical social services provided by the MSW. Services might have included short-term counseling services, referral to and coordination with community resources and assistance with living arrangements, finances and long-range planning. The agency’s Scope of Services and Objectives policy dated 10/01/1995, documented the scope of services should include, but not necessarily be limited to: Skilled Nursing, Certified Nurse Aide services, Physical. Occupational, and Speech Therapy, Medical Social Services, and Intravenous Therapy. The agency’s Professional and Ancillary Services policy (undated), documented the MSW services should be provided directly or under arrangement by a qualified Social Worker or Social Work Assistant under the supervision of a qualified Clinical Supervisor and in accordance with the physician’s written orders. On 03/12/2024, the Assistant Administrator provided a copy of the list of the agency’s active employees and contract for professional and ancillary services. The documents provided did not include a qualified MSW to perform the social services as advertised and indicated in the above-mentioned brochure, booklet, and policies. On 03/14/2024 at 10:48 AM, the Assistant Administrator confirmed the findings and revealed the agency used to have a contract with an MSW to provide the social services to the patients. The Assistant Administrator acknowledged the agency should have maintained the contract to provide the social services needs of the patients. On 03/14/2024 1:34 PM, the Assistant Administrator indicated the last day of work of the former MSW was on 10/31/2022.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on interview, record review and document review, the agency failed to ensure a supervisory visit for a certified nursing assistant (CNA)/home health aide (HHA) was performed every 14 days for 1 of 8 sampled patients (Patient 4). The deficient practice had the potential for failing to assess the competence and the quality of services provided by the HHA in a timely manner. Findings include: Patient 4 (P4) P4 was admitted on 02/12/2024, with diagnoses including chronic obstructive pulmonary disease and bacterial pneumonia. P4’s orders for discipline and treatments dated 02/12/2024, documented the following: - Skilled Nursing (SN) once every week for nine weeks - Home Health Aide once every week for nine weeks P4’s medical record documented the following visits was provided to the patient: - Week 1: SN on 02/12/2024 and HHA on 02/15/2024 - Week 2: HHA on 02/20/2024 and SN on 02/21/2024 - Week 3: SN on 02/26/2024 and HHA on 02/28/2024 P4’s medical record lacked documented evidence the Registered Nurse (RN/Skilled Nursing) performed a supervisory visit with the HHA. On 03/13/2024 at 1:57 PM, the Director of Nursing (DON) confirmed the findings and explained the RN should have performed the supervisory visit every 14 days or during Week 2 of P4’s scheduled visits. The DON indicated the notes or results of the supervisory visit should have been documented in the SN Visit Note. The agency’s policy titled Certified Nurse Aide Services dated 10/01/1995, documented the supervision of the aide should be by a registered nurse to ensure the aide’s competence in providing home health care. Aide’s care should be supervised at least every 14 days. At least one visit each month must have occurred when the aide was delivering care.