Every finding on record at All Care Home Health, Inc

A partial extended survey for Medicare recertification for the home health provider was completed on 09/14/2022. The agency had 11 current patients. The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 09/14/2022. Three standard level deficiencies were identified.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on review of the home health agency's Emergency Preparedness (EP) binder and interview, the agency failed to include a comprehensive process for cooperation and collaboration with local, regional, state and federal EP officials. This deficient practice has the potential to adversely affect the care and safety of all patients served by the agency during an emergency. Findings included: Review of the EP binder failed to show evidence of the home health agency’s comprehensive process to ensure cooperation and collaboration with local, regional, state, and federal EP officials. During an interview on 09/14/2022 at 9:35 AM, the administrator stated that they contacted the police station and no further information was provided.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on review of the agency's emergency preparedness plan, and interview, the agency failed to ensure their emergency preparedness communication plan included a clear method for sharing medical information about patients with other healthcare providers. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's emergency preparedness communication plan failed to include a method for sharing medical information about patients with other healthcare providers. The findings were reviewed with the administrator on 09/14/2022 at 9:35 AM and no further information was provided.

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), §485.625(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, 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 review of the agency's Emergency Preparedness (EP) manual and interview, the agency failed to conduct exercises to test the emergency plan annually, analyze the agency’s response to, and maintain documentation of all drills, tabletop exercises, and emergency events. This deficient practice has the potential to adversely affect the care and safety of all patients served by the agency during an emergency. Findings included: Review of the agency's EP binder failed to show documentation of an emergency and community based exercises in 2020 and 2021. On 05/12/2022, there was documentation of a tornado drill and the attendees were the administrator and administrator designee. The agency failed to analyze the agency’s response to the tornado drill. During an interview on 09/13/2022 at 3:12 PM, the administrator stated that he/she and the alternate administrator conducted a tabletop emergency; there was no documentation to show analyzing the agency’s response. The home health agency had conducted other drills and tabletop exercises, however they did not doucment the exercises. There was no further information provided.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on policy review, review of the agency’s current patient rights information and interview, the agency failed to provide written notice of patient rights regarding their right to have a copy of the patient’s rights and responsibilities provided to a patient-selected representative within four business days of the initial evaluation visit. This deficient practice has the potential to adversely affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Patient Rights”, dated 2016, showed it failed to contain information that the home health agency must provide written notice of the patient’s rights and responsibilities under this rule and the HHA’s (home health agency) transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 (four) business days of the initial evaluation visit. Review of the agency’s current admission package client information handbook provided to this surveyor on 09/12/2022 by the administrator, showed it failed to contain written information regarding the home health agency must provide written notice of the patient’s rights and responsibilities under this rule and the HHA’s (home health agency) transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 (four) business days of the initial evaluation visit. During an interview on 09/14/2022 at 4:12 PM, when discussing the portion of the rights regarding providing written notice of the patient’s rights and responsibilities to a patient-selected representative within 4 business days, the administrator stated that the 4 business days isn’t in there.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on policy review, review of the agency’s current patient rights information and interview, the agency failed to provide written notice to the patient of their right to be advised orally and in writing of the extent to which payment for HHA (home health agency) services may be expected. This deficient practice has the potential to adversely affect the knowledge and comprehension of the rights and responsibilities of all the agency’s patients. Findings included: Review of the agency’s policy titled, “Patient’s Right’s”, dated 2016, showed, in part: - Page 125 of 488: Homecare agency protects and promotes the rights of each individual under its care. Homecare agency will provide information regarding the patient bill of rights and responsibilities, both verbally and in writing, to all Homecare agency staff upon hire and to each patient prior to admission to Homecare agency; and - Page 126 of 488: The patient’s rights include each of the following rights- be informed, both orally and in writing, in advance of care being provided, of the charges, including payment for service/care expected from third parties and any charges for which the patient will be responsible. Review of the agency’s current admission package client information handbook provided to this surveyor on 09/12/2022 by the administrator, showed it failed to contain written information regarding the patient’s right to be advised, orally and in writing, of the extent to which payment for HHA services may be expected. During an interview on 09/14/2022 at 4:12 PM, when discussing the portion of the patient rights regarding the patient’s right to be advised, orally and in writing, of the extent to which payment for HHA services may be expected, the administrator stated that: - Orally and in writing isn’t there exactly; - It does have, on page 18, their right to “receive information about care and treatment to be provided in writing and in a manner that you understand from the Home Health Agency and from others outside the organization and be fully informed of and changes in the care and treatment to be furnished by the Home Health Agency and from other outside the organization; and - “We do it, it just isn’t written in the rights that way.”

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on policy review, review of the agency’s current patient rights information and interview, the agency failed to provide written notice of the correct state toll free home health hotline number and its hours of operation. This deficient practice has the potential to adversely affect the knowledge and comprehension of the rights and responsibilities of all the agency’s patients. Findings included: Review of the agency’s policy titled, “Patient Rights”, dated 2016, showed: - Home Health Hotline- the patient has the right to be advised of the availability of the toll-free HHA (home health agency) hotline in the state; and - When the homecare agency accepts the patient for treatment or care, the agency will advise the patient in writing of the telephone number of the home health hotline established by the state, the hours of operation and the purpose of the hotline is to receive complaints or questions about local HHA’s. Review of the agency’s current admission package client information handbook provided to this surveyor on 09/12/2022 by the administrator showed: - Inside the front cover page- To report abuse, neglect or exploitation, please call the toll-free number: 1-800-735-2966 (incorrect number). The number is available 7 days a week, 24 (twenty four) hours a day (incorrect hours of operation); and - Inside the back cover page- Missouri Adult abuse and neglect hotline: 1-800-392-0210 (the correct number but failed to list any hours of operation. During an interview on 09/14/2022 at 4:12 PM, when discussing the portion of the patient rights regarding state toll free home health hotline number and its hours of operation, the administrator: - Acknowledged that the phone number and hours on the inside of the front cover of the current admission package client information handbook were incorrect; - Stated that the inside cover of the back page had the correct phone number, but there were no hours of operation listed; and - The hotline number and hours would be fixed.

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 policy review, record review, home visit observation, and interview, the agency failed to review all of the patient's current medications to maintain an accurate/updated medication profile in one (Record/Patient #3) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency’s policy titled, “Medication Regimen Review- Comprehensive,” dated 2017, showed, in part, the following: - Policy: The registered nurse (RN) will be responsible for monitoring the patient’s medication regimen through a collaborative effort with multi-disciplinary team and physician involved with the patient’s care; - At the time of admission an accurate, current and complete list of all prescription and over-the-counter (OTC) medications taken by the patient will be maintained on the medication profile; - The nurse will compare the list to those on the referral or other documents provided to the agency; and - Any discrepancies will be reconciled with the physician and documented in the clinical record. RECORD/PATIENT #3: The hospital discharge summary dated 09/03/2022, showed to continue taking acetaminophen (pain reliever) 500 milligrams (mg) and atorvastatin (used to treat high cholesterol and trigyceride levels) 40 mg tablet. Review of the plan of care (POC) dated 09/07/2022 to 11/05/2022 showed, in part, alprazolam (sedative) 0.25 mg, one tablet, two times daily. The agency failed to include acetaminophen and atorvastatin per the hospital discharge summary. Review of the patient’s medications list, provided by the assisted living facility (ALF), during a home visit on 09/13/2022 at 10:20 AM, showed the following: - Acetaminophen 325 mg, two tablets every four hours as needed; - Alprazolam 0.5 mg, one tablet twice daily as needed (POC shows alprazolam 0.25 mg twice daily, not as needed); - Alprazolam 0.5 mg, one tablet at bedtime; - Ondansetron ODT (prevents nausea and vomiting) 4 mg, one tablet, three times daily and two times daily as needed; and - Ondansetron ODT 4 mg, twice daily as needed for nausea and vomiting. Review of the medical record showed the agency failed to include acetaminophen, ondansetron, and alprazolam 0.5 mg at bedtime and clarify the discrepancy of the alprazolam dosage and if alprazolam to be given twice daily or as needed. During interview on 09/14/2022 at 9:35 AM, the clinical manager stated that the admitting nurse or physical therapist are to compare the patient’s medication with the discharge medication and the medication in the patient’s home. If there are discrepancies, the staff are to notify the physician and include all medications in the start of care order and document any discrepancies and physician notification.

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 record review and interview, the agency failed to ensure the plan of care (POC) included all of the required elements in two (Records/Patients #3 and #4) of five full record reviews. This deficient practice has the potential to affect the care of all patients served by the agency. Findings included: Review of the agency’s policy titled, “Plan of Care/Physician Orders,” dated 2016, showed the following: - An individualized plan of care will be developed for each patient admitted to homecare and reviewed/revised as needed to meet the patient’s needs; - The plan of care is developed and based on assessment information provided by the various members of the interdisciplinary team; and - Nurses, social workers, home care aides, physicians, and other members collaborate in the development of the plan of care. RECORD/PATIENT #3: Review of the physical therapy (PT) start of care (SOC) assessment dated 09/07/2022 showed: - Diagnosis included acute cystitis (sudden inflammation of the urinary bladder), klebsiella pneumonia (bacteria that usually normally live in your intestines and feces), dementia, Alzheimer’s disease, and history of stroke; - The patient had a urinary tract infection (UTI) in the past 14 days, memory deficit, impaired decision making, disruptive behaviors at least daily, and increased risk for falls; - The patient attempts to leave walker to his/her side and ambulate without use of an assistive device, holding onto walls and furniture; and - Takes aspirin (nonsteroidal anti-inflammatory and blood thinner) 81 milligrams once a day and clopidogrel (blood thinner) 75 mg once a day. Review of the physical therapy assistant (PTA) assessment dated 09/09/2022, showed: - The patient was educated on anticoagulation precautions and monitoring to prevent bleeding; - The patient was instructed to take pain medications 40 minutes before treatment for pain relief (there was no evidence of pain); and - Teaching was provided on energy conservation techniques. Review of the POC dated 08/08/2022 through 10/06/2022, showed the following: - PT [physical therapy] to minimize/eliminate risk for hospitalization due to high-risk principal diagnosis UTI and Alzheimer’s; - The POC failed to include individualized interventions to monitor and prevent UTI’s; - The POC failed to include disruptive behaviors and anticoagulation (blood thinner) use; - Patient identified as high risk for falls and the POC failed to include individualized interventions, including patient ambulating without an assistive device; and - The POC failed to include pain interventions and energy conservation techniques. Observation on 09/13/2022 at 10:20 AM, during the patient’s home visit, showed the occupational therapist (OTA) was trying to put a gait belt on the patient and the patient kept saying “I don’t like it” and the patient started to bite his/her own hand. OTA told the patient his/her son wanted him/her to walk and this calmed the patient. Throughout the visit, the patient kept saying “I don’t like it” and biting his/her hand. The OTA helped the patient into bed and placed the walker on the side of the bed because the patient tries to get up without help. PATIENT/RECORD #4 Review of the physical therapy start of care (SOC) dated 08/08/2022 at 2:10 PM, showed: - The patient’s primary diagnosis was type two diabetes mellitus (a chronic condition that affect the way the body processes blood sugar [glucose]) with diabetic polyneuropathy (a complication of diabetic mellitus characterized by progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers); - Other diagnosis included congestive heart failure (CHF [a chronic condition in which the heart does not pump blood as well as it should]); long-term use of insulin (regulates the amount of glucose in the blood); and - The patient’s area of interest included what to eat, how to manage symptoms, when to seek help, and how to stay out of the hospital. Review of the PTA visit note dated 08/11/2022 at 9:40 AM, showed: - Teaching provided on pain management, the patient was instructed to take prescribed pain medication 40 minutes prior to therapy session as needed for pain relief (there was no evidence of pain); - Patient demonstrates no signs/symptoms of hypoglycemia and hyperglycemia; - Instructed patient on hypoglycemia and hyperglycemia management and long-term diabetes complications and teaching done on signs and symptoms of hypoglycemia and hyperglycemia to report; and - Teaching energy conservation techniques and safe and effective breathing. Review of the POC dated 08/08/2022 through 10/06/2022 failed to include the following: - Diabetes education and monitoring, signs and symptoms of hypoglycemia and hyperglycemia, how often to check blood glucose, education on nutrition, and assessing the patient’s feet; - CHF; - Energy conservation techniques and safe and effective breathing; and - Pain management including instructing the patient to take pain management 40 minutes prior to therapy. During an interview on 09/14/2022 at 9:35 AM, the clinical manager stated that all care should be included on the POC, including diabetes, anticoagulant use, behaviors, and pain. The POC should include individualized interventions.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to obtain orders to provide services and treatments only as ordered by a physician or allowed practitioner in three (Records/Patients #1, #3, and #4) of five full records reviewed. This deficient practice has the potential to adversely affect physician driven care of all agency patients. Findings included: Review of the policy titled, “Plan of Care/Physician Orders”, dated 2016 showed, in part: - The initial plan of care must include at a minimum, these items- orders for specific home health care serviced, disciplines, treatments, and procedures (specify amount/frequency/duration); - Physician orders are needed to provide any homecare services, including all support services related to client/patient care, and any services requiring the administration of medication, prescribed treatment(s), or other activities governed by state law; - Services are provided under an individualized plan of care that is established by the primary care physician, the home care staff and the patient; and - The plan of care will serve as physician’s orders for the patient care and all staff providing services will be in compliance with the orders. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to the agency on 08/09/2022 with a principal diagnosis of drug-induce myopathy (occurs when a drug causes a toxic effect that results in myalgia (muscle pain), muscle damage, and/or muscle breakdown. Review of a skilled nurse visit report dated 08/26/2022 showed narrative documentation stating “Instructed on pain management including distraction therapy, hot compress for no more than 20 minutes at a time and at least 20 minutes in between episodes of heat application.” (No location of where to apply the heat was documented). Review of the plan of care dated 08/09/2022 through 10/07/2022 failed to show any orders for heat application. Further review of the clinical record failed to show any interim orders for heat application. During an interview on 09/13/2022 at 4:12 PM, the administrator stated that he/she would expect an order for heat application including location/duration/frequency prior to educating patient to utilize it. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health on 09/07/2022. Diagnosis included acute cystitis (sudden inflammation of the urinary bladder), klebsiella pneumonia (bacteria that usually normally live in your intestines and feces), dementia, Alzheimer’s disease, and history of stroke. Review of the physical therapy assistant (PTA) assessment dated 09/09/2022, showed: - The patient was educated on anticoagulation precautions and monitoring to prevent bleeding; - The patient was instructed to take pain medications 40 minutes before treatment for pain relief (there was no evidence of pain); and - Teaching was provided on energy conservation techniques. Review of the POC dated 08/08/2022 through 10/06/2022, failed to show physician orders for anticoagulation precautions and monitoring to prevent bleeding, the patient to take pain medications 40 minutes prior to treatment, and provide energy conservation techniquies. PATIENT/RECORD #4 Review of the clinical record showed the patient was admitted to home health on 08/08/2022. The patient’s primary diagnosis was type two diabetes mellitus (a chronic condition that affect the way the body processes blood sugar [glucose]) with diabetic polyneuropathy (a complication of diabetic mellitus characterized by progressive death of nerve fibers, which leads to loss of nerves, increased sensitivity, and the development of foot ulcers). Other diagnosis included congestive heart failure (CHF [a chronic condition in which the heart does not pump blood as well as it should]); long-term use of insulin (regulates the amount of glucose in the blood); and Review of the PTA visit note dated 08/11/2022 at 9:40 AM, showed: - Teaching provided on pain management, the patient was instructed to take prescribed pain medication 40 minutes prior to therapy session as needed for pain relief (there was no evidence of pain); - Patient demonstrates no signs/symptoms of hypoglycemia and hyperglycemia; - Instructed patient on hypoglycemia and hyperglycemia management and long-term diabetes complications and teaching done on signs and symptoms of hypoglycemia and hyperglycemia to report; and - Teaching energy conservation techniques and safe and effective breathing. Review of the POC dated 08/08/2022 through 10/06/2022 failed to include the following: - Diabetes education and monitoring, signs and symptoms of hypoglycemia and hyperglycemia; - Energy conservation techniques and safe and effective breathing; and - Pain management including instructing the patient to take pain management 40 minutes prior to therapy. During an interview on 09/14/2022 at 9:35 AM, the clinical manager stated that all care should be included on the POC, including diabetes, anticoagulant use, behaviors, and pain.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, record review and interview, the agency failed to notify/communicate with the physician regarding patient care changes in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to adversely affect the care of all patients served by the agency. Findings included: Review of the agency's policy titled, “Plan of Care/Physician Orders”, dated 2016 showed, in part: - The initial plan of care must include at a minimum, these items- orders for specific home health care serviced, disciplines, treatments, and procedures (specify amount/frequency/duration); - Physician orders are needed to provide any homecare services, including all support services related to client/patient care, and any services requiring the administration of medication, prescribed treatment(s), or other activities governed by state law; - The organization has a responsibility to obtain physician orders prior to initiation of the services and to notify the physician of any changes in the client/patient’s condition; - Services are provided under an individualized plan of care that is established by the primary care physician, the home care staff and the patient; and - The plan of care will serve as physician’s orders for the patient care and all staff providing services will be in compliance with the orders. RECORD/PATIENT #1: Review of the home health certification and plan of care (order # 49695263) dated 8/9/2022 through 10/07/2022 showed, in part: - Notify physician of vital parameters out or range: Systolic (measures the pressure in your arteries when your heart beats- the first/top number) BP (blood pressure) greater than 160 and less than 90; and diastolic (measures the pressure in your arteries when your heart rests- the second/bottom number) BP greater than 99 and less than 60. Review of the start of care OASIS (Outcome and Assessment Information Set- a standardized assessment form), dated 8/9/2022 showed: - BP standing 84 (systolic)/62 (diastolic); and - Failed to show documentation of physician notification/communication regarding the systolic pressure of 84 (less than 90 which was to be reported). During an interview on 09/13/2022 at 4:12 PM the administrator stated that he/she generally would expect the BP out of range be reported to the physician.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on home visit observation and interview, the agency failed to ensure each patient received written information related to the name and contact information of the agency’s clinical manager in the admission package client information handbook in three (Records/Patients #1, #2, and #3) of three home visit observations. Findings included: RECORD/PATIENT #1: Observation on 09/13/2022 at 8:31 AM, during the patient’s home visit observation, the admission package client information handbook was reviewed and the front of the admission package client information handbook had Director of Nursing/Clinical Manager: with a line to fill in that was left blank. Further review of the admission handbook failed to list the name and contact information of the clinical manager. RECORD/PATIENT #2: Observation on 09/13/2022 at 11:32 AM, during the patient’s home visit observation, the admission package client information handbook was reviewed and the front of the handbook had Director of Nursing/Clinical Manager: with a line to fill in that was left blank. Further review of the admission handbook failed to list the name and contact information of the clinical manager. RECORD/PATIENT #3: Kellie During an interview on 09/13/2022 at 10:00 AM, the administrator stated that: - It is a mistake that shouldn’t have been made; and - He/she would expect the front of the booklet to be filled out with names and contact information. RECORD/PATIENT #3: Observation on 09/13/2022 at 10:20 AM, during the patient’s home visit observation, the admission package client information handbook was reviewed and the front of the admission package client information handbook had Director of Nursing/Clinical Manager: with a line to fill in that was left blank. Further review of the admission handbook failed to list the name and contact information of the clinical manager.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to send a completed transfer summary to the healthcare facility that the patient was receiving care within two business days of becoming aware of an unplanned transfer in one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to adversely affect the continued care needs for all patients transferred from the agency. Findings included: Review of the agency’s policy titled, “Coordination of Care-Transfer Patient”, dated 2017, showed, in part, when a patient is transferred to a hospital, nursing home, or entity: - The homecare agency will contact the receiving entity to give a transfer summary of the patient’s medical condition which includes: * Date of transfer; * Patient identifying information; * Emergency contact; * Destination of patient transferred; * Date and name of person receiving report; * Patient’s physician and phone number; * Diagnosis related to transfer; * Significant health history; *Transfer orders and instructions; * A brief description of services provided and ongoing needs that cannot be met; * Status of the patient at the time of transfer; * Psychosocial status; and * Any existing advance directives; and - The discharge/transfer summary/order and current plan of care will be sent to the receiving entity upon request. RECORD/PATIENT #1: Review of the clinical record showed, in part: - The patient was admitted to the agency on 08/09/2022 with a principal diagnosis of drug-induce myopathy (occurs when a drug causes a toxic effect that results in myalgia (muscle pain), muscle damage, and/or muscle breakdown; - A communication note dated 08/20/2022 stated that the patient was being taken to “Named Hospital” via EMS (Emergency Medical Services) due to worsening confusion, weakness, and behavioral changes. The attending physician and the agency administrator were notified; - A transfer OASIS (Outcome and Assessment Information Set- a standardized assessment), dated 08/20/2022 showed under the Notifications section, Copy of transfer summary sent to: with physician check marked and inpatient receiving facility left blank; and - A fax transmission status form dated 08/23/2020 showed: Please find the attached written orders to be signed, dated and returned within 30 (thirty) days of the written order date. When dating, please be sure to confirm it is within 30 days of the order date. Please return all signed orders at your earliest convenience to “agency fax number”. If for any reason you are unable to fulfill this request, please contact our office immediately. During an interview on 09/13/2022 at 10:32 AM, the clinical manager stated that: - They utilized the OASIS transfer as the transfer summary; - It (the OASIS transfer) was not sent to the hospital (receiving institution); - He/she was unsure why the inclusion of the transfer OASIS was not mentioned as being sent on the fax transmission amidst the discussion about signing the orders.