Every finding on record at All Solutions Healthcare, Inc

The Emergency Preparedness requirements were evaluated in conjunction with the recertification survey, on 9/28/23. Standard level deficiencies cited. Abbreviations: Pt./Pts.= Patient/Patients

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on review of the Agency's Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to review and update its Emergency Preparedness Plan biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan binder was reviewed on 9/26/23 at 11:30 AM. The Plan was last reviewed on 3/15/2020. 2. During an interview with the Administrator, Director of Nursing and Registered Nurse on 9/27/23 at 3:30 PM, the administrative staff confirmed the above findings.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on review of the Agency's Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to ensure an updated risk assessment was completed utilizing an all-hazards approach. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 9/26/23 at 11:30 AM. The plan included an all hazards risk assessment dated 3/15/2020. The plan lacked an updated all hazards risk assessment. 2. During an interview with the Administrator, Director of Nursing and Registered Nurse on 9/27/23 at 3:30 PM, the administrative staff confirmed the above finding.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on review of Agency's Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to have a communication plan that included an accurate list of required names and contact information. This has the potential to affect all patients who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 9/25/23. The plan lacked a communication plan that meets the following requirements: Current list of names and contact information for staff members and entities providing service under contract, and Patient’s Physicians providing care. 2. During an interview with the Administrator, Director of Nursing and Registered Nurse on 9/27/23 at 3:30 PM, the administrative staff confirmed the Agency failed to ensure the Agency’s Emergency Preparedness communication plan was complete and accurate.

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 review of the Agency's Emergency Preparedness Plan and staff interviews, it was determined the Agency failed to ensure the Agency conducted Emergency Preparedness testing. Findings Include: 1. The Agency's Emergency Preparedness Plan was reviewed on 9/26/23 at 11:30 AM. The Emergency Preparedness Plan lacked documentation indicating that the Agency participated in or conducted any testing of the Emergency Preparedness, since 2020. 2. During an interview with the Administrator, Director of Nursing and Registered Nurse on 9/27/23 at 3:30 PM, the administrative staff confirmed the Agency failed to conduct/participate in any testing or drills since 2020.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 9/28/23. Standard level deficiencies cited. An investigation was conducted on 9/28/23 for Complaint # IL71431/222988. Standard level deficiencies cited. Abbreviations: SN = Skilled Nurse Pt./Pts. = Patient/Patients E = Employee # = Number AM = Morning PM = Evening SOC= Start of Care PT = Physical Therapist OT = Occupational Therapist OASIS = Outcome and Assessment Information Set

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interviews, it was determined the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. This was found in 2 of 7 (Pts. #3 and 4) clinical records reviewed. 1. Pt. #3 was admitted to Home Health Services on 8/17/23 with the principal diagnosis of Left Ventricular Failure, unspecified. The clinical record was reviewed on 9/26/23 and included a SOC comprehensive assessment dated 8/17/23. The record included the Physician’s order/referral dated 8/14/23, requiring the Pt. to receive SN services. The Agency failed to start service within 48 hours of order received by the Agency on 8/14/23. 2. Pt. #4 was admitted to Home Health Services on 7/24/23 with the principal diagnosis of Peripheral Vascular Disease, unspecified. The clinical record was reviewed on 9/26/23 and included a SOC comprehensive assessment dated 7/24/23. The record included the Physician’s order/referral dated 7/19/23, requiring the Pt. to receive SN, PT and OT services. The Agency failed to start service within 48 hours of order received by the Agency on 7/19/23. 3. During an interview with the Administrator, Director of Nursing (DON) and Registered Nurse on 9/27/23 at 3:30 PM, the administrative team confirmed that the patients should have been admitted within 48 hours of the referral.

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 record reviews and interviews, it was determined the Agency failed to ensure the Physician was notified regarding changes in Pt. condition for 3 of 7 (Pts. # 2, #6 and #7) clinical records reviewed. Findings include: 1. Pt. #2 was admitted for skilled home health services on 9/1/23 with the Principal Diagnosis of Essential (Primary) Hypertension. The clinical record was reviewed on 9/27/23. The clinical record included a Plan of Care for the period of 9/1/23 to 10/30/23 requiring: “Orders for Discipline and Treatment: Notify Physician of vital sign parameters out of range: Heart Rate: Greater than 100, less than 60…” Pt. #2’s Occupational Therapy Note dated 9/14/23 included documentation of a heart rate of 106. The clinical record lacked documentation of Physician notification or a reason why the physician was not notified of the heart rate, which was not within the parameters. 2. Pt. # 6 was admitted for skilled home health services on 7/2/21 with the Principal Diagnosis of Cerebral Infarction. The clinical record was reviewed on 9/27/23. The clinical record included a Plan of Care for the period of 7/2/21 to 8/30/21 requiring: “Orders for Discipline and Treatment: Notify Physician of vital sign parameters out of range: Systolic Blood Pressure: Greater than 160, less than 90, Diastolic Blood Pressure: Greater than 90, less than 60…” Pt. #6’s Home Health Aide Notes included documentation of blood pressure reading of 100/58 for the following dates: 7/27/21, 8/3/21, 8/6/21, 8/10/21, and 8/13/21. The clinical record lacked documentation that the Registered Nurse was notified. The record also lacked documentation of Physician notification or a reason why the Physician was not notified of the blood pressure results which were not within the parameters. During an interview on 9/27/23 at 2:40 PM, E #1 (Registered Nurse/Director of Nursing) stated that the Home Health Aide did not inform E#1 of the blood pressure readings that were out of parameters. E#1 stated that E#1 would have notified the Physician right away and document it in the clinical record. 3. Pt. # 7 was admitted for skilled home health services on 7/16/21 with the Principal Diagnosis of Essential (Primary) Hypertension. The clinical record was reviewed on 9/27/23. The clinical record included a Plan of Care for the period of 7/2/21 to 8/30/21 requiring: “Orders for Discipline and Treatment: SN to recognize and intervene to minimize complications: notify Physician immediately of any potential problems that may impede completion of patient recovery and desired goals…” Pt. #7’s Start of Care OASIS dated 7/16/21 included documentation of a weight of 138 pounds. The following weights were listed on the Skilled Visit Notes: 7/23/21 (1 week after) = 121 pounds, which is a 17-pound weight loss, 8/16/21 (1 month after) = 119 pounds, which is a 19-pound weight loss from start of care. Pt. #7 was also re-admitted for skilled home health services again on 10/8/21. Pt. #7’s Start of Care OASIS dated 10/8/21 included documentation of a weight of 138 pounds. The following weights were listed on the Skilled Visit Notes: 10/18/21 (2 weeks after) = 110 pounds, which is a 28-pound weight loss, 10/28/23 = 112 pounds (3 months after first Start of Care), which is a 26-pound weight loss from start of care. The record lacked documentation of physician notification or a reason why the physician was not notified of the weight loss. During an interview with the E#2 (Registered Nurse) on 9/28/23, it was stated that for all Agency Pts., the Agency follows the policy used for reporting weight changes for Congestive Heart Failure Pts. to the Physician. E#2 stated staff should report significant weight loss to the Physician. 4. The Agency Policy “Change in Condition Reporting” was reviewed on 9/28/23. The policy requires, “When there is a significant change in client’s response to care, condition, diagnosis and environment or support…1. The Registered Nurse…or occupational Therapist is responsible…Clients’ overall condition, pertinent physical findings, response to treatment or therapy, adequacy of the current Plan of care…2. Changes in condition are consulted with the physician and communicated to the appropriate disciplines.” 5. The Agency Policy “Reporting Changes in Weight for Clients with Congestive Heart Failure" was reviewed and required, “When there is a significant change in client’s weight, medical condition and adverse symptoms… 2. Changes in condition are consulted with the physician and communicated to the appropriate disciplines.” 6. The Agency Policy "Nutrition" was reviewed on 9/28/23 and required, "8. Report to physician weight loss of 5 pounds or more within 30 days." 7. During an interview with E #1, E#2 and E #6 (Administrator) on 9/28/23 at 2:40 PM, the above findings were confirmed.

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 review of the Agency's Pt. admission folder and staff interviews, it was determined the Agency failed to provide information regarding the Clinical Manager (Director of Nursing) and their contact information. This has the potential to affect all Pts. admitted to the Agency. Findings include: 1. The Agency Pt. admission folder was reviewed on 09/25/23. The folder lacked information identifying the Director of Nursing name and contact information. 2. During staff interviews with the Administrator, Director of Nursing and Registered Nurse on 09/27/23 at 3:30 PM, it was indicated the same admission folder is given to all Patients. The administrative staff also confirmed the above findings.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on a home visit observation, review of clinical records and staff interview, it was determined the Agency failed to ensure forms were complete and accurate. This was found in 3 of 3 (Pts. #1, 2 and 3) Pt. folders reviewed during home visit. 3. Pt. #3 was admitted to Home Health Services on 8/17/23 with the principal diagnosis of Left Ventricular Failure, unspecified. The clinical record was reviewed on 9/26/23 and included a SOC comprehensive assessment dated 8/17/23. During the home visit conducted with the Director of Nursing on 9/26/23 the home folder was reviewed. The folder included the "Notice of Medicare Non-Coverage" document. The section of the document “The Effective Date Coverage Your Current Home Health Services Will End:” was left blank. The document was signed by the Pt. but not dated. 4. During staff interviews with the Administrator, Director of Nursing and Registered Nurse on 09/27/23 at 3:30 PM, the above findings were confirmed. Findings include: 1. Pt. #1 was admitted for skilled home health services with a Principal Diagnosis of Parkinson’s Disease. During a home visit was conducted with the E#2 (Registered Nurse) on 9/26/23 the home folder was reviewed. The folder contained the "Notice of Medicare Non-Coverage" document. The section of the document “The Effective Date Coverage Your Current Home Health Services Will End:” was left blank. The document was signed by the Pt., and but not dated. 2. Pt. #2 was admitted for skilled home health services with a Principal Diagnosis of Essential (Primary) Hypertension. During a home visit was conducted with the E#4 (Physical Therapist) on 9/26/23 the home folder was reviewed. The folder contained the "Notice of Medicare Non-Coverage" document. The section of the document “The Effective Date Coverage Your Current Home Health Services Will End:” was left blank. The document was signed by the Pt., and but not dated.