Every finding on record at Alliance Express Home Care Services LLC

EMERGENCY PREPAREDNESS SURVEY The following deficiencies are based on the emergency preparedness survey completed 10/19/23.

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 record review and staff interview, the agency failed to ensure the Emergency Preparedness Plan was reviewed and updated every two years. This could potentially affect all patients receiving services from the agency. The census was 38. Findings include: Review of the agency policy titled, “Emergency Operations Plan and Policies,” revised 06/2017, revealed the agency has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least annually. Review of the Emergency Preparedness Plan did not reveal documentation the last time it was reviewed or updated. Interview on 10/19/23 at 2:10 PM with Staff C confirmed there was no documentation of the last time the Emergency Preparedness Plan was reviewed and updated.

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 record review and staff interview, the agency failed to ensure the hazard risk assessment was reviewed and updated every two years. This could potentially affect all patients receiving services from the agency. The census was 38. Findings include: Review of the agency policy titled, “Agency-Based and Community-Based Risk Assessment,” revised 06/2017, revealed the Hazard Vulnerability Analysis (HVA) will be conducted and evaluated annually. Review of the emergency preparedness plan revealed the last Agency-Based and Community-Based Risk Assessment was reviewed and updated in 2019. Interview on 10/19/23 at 11:45 AM with Staff C confirmed the last hazard risk assessment provided was from 2019.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure emergency preparedness policies included procedures to inform State and local emergency preparedness officials about patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This could potentially affect all patients receiving services from the agency. The census was 38. Findings include: Review of the agency policy titled, “Emergency Operations Plan and Policies,” revised 06/2017, revealed the agency will maintain a list of patients with acuity level established and will maintain at all times a current list of patients who might need evacuation. Review of the emergency preparedness plan did not reveal a list of patients with acuity level established or a list of patients who might need evacuation. Interview on 10/19/23 at 2:30 PM with Staff C confirmed this 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 record review and staff interview, the agency failed to ensure all staff emergency contact information was included in the Emergency Preparedness Plan. This could potentially affect all patients receiving services from the agency. The census was 38. Findings include: Review of the agency’s policy titled, “Communication Plan and Policy for Emergency Operations Plan,” revised 06/2017, revealed the communication plan includes the names and contact information for the staff. Review of the Emergency Preparedness Plan revealed a list of three staff out of 38. Interview on 10/19/23 at 12:36 PM with Staff C confirmed not all staff emergency contact numbers were available.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to conduct exercises to test the emergency plan at least annually. This could potentially affect all patients receiving services from the agency. The census was 38. Findings include: Review of the agency’s policy titled, “Testing Program for Emergency Operations Plan (EOP),” revised 06/2017, revealed the agency will conduct exercises to test the EOP at least annually. The agency will analyze the agency’s response to and maintain documentation of all drills, tabletop exercises and emergency events. Review of the emergency preparedness plan revealed the last drill/exercise and evaluation produced was 11/29/19. Interview on 10/19/23 at 12:06 PM with Staff A confirmed the last drill/exercise produced was 11/29/19.

Partial Extended Recertification Survey An entrance conference was conducted on 10/16/23 at 9:57 AM with administrative staff. An exit conference was conducted on 10/19/23 at 3:45 PM with administrative staff. The following deficiencies are based on the partial extended recertification survey completed 10/19/23. Alliance Express Home Care Services LLC 369242, is not in compliance with the requirements at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

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 observation, policy review, record review, and staff interview, the agency failed to ensure a review of all medications the patient was currently using for two of three patients observed during home visits (Patient #1 and #2). The total sample was seven patients. The census was 38. Findings include: Review of the agency policy titled, “Medication Reconciliation” revised 2014, revealed at the time of admission, the admitting registered nurse will create and document a complete list of medications that the patient is taking at home, including dose, route, and frequency. Any discrepancies will be reconciled by the registered nurse with the patient’s physician. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. 1. A home visit was made to Patient #1 on 10/17/23 at 8:00 AM with Staff D present. Review of the medication profile revealed an order for Oxygen 0.5 milliliters (ml) as needed for respiratory distress. Interview on 10/17/23 at 8:25 AM with Staff D revealed Patient #1 used Oxygen at 2 Liters/minute as needed. Staff D confirmed Oxygen at 2 Liters/minute as needed was not listed on the medication profile. 2. A home visit was made to Patient #2 on 10/17/23 at 9:30 AM with Staff A present. Staff A was observed to give Patient #2 45 Units of Novolog insulin. Review of the current medication profile did not list Novolog insulin. Interview on 10/17/23 at 9:48 AM with Staff A revealed Patient #2 had been on 45 Units of Novolog insulin three times a day for two months. Staff A confirmed Novolog insulin was not listed on the current medication profile. Review of the medication bottles in the home revealed a bottle of Vitamin D2 1.25 milligrams (mg) to be taken weekly. This was filled on 08/23/23. The current medication profile did not include Vitamin D2 1.25 milligrams (mg) to be taken weekly. Interview on 10/17/23 at 9:52 AM Staff A confirmed Vitamin D2 1.25 milligrams (mg) to be taken weekly was not on the current medication profile. Further review of the medication bottles in the home revealed a bottle of Gabapentin 800 milligrams (mg) to be taken three times a day. This was filled on 09/28/23. Review of Patient #2's medication profile revealed and order for Gabapentin 300 mg three times a day. Interview on 10/17/23 at 9:55 AM with Staff A revealed she was aware Patient #2 was on Gabapentin 800 mg and confirmed Gabapentin 800 mg was not listed on the medication profile. Staff A confirmed the medication profile was not updated.

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 record review, policy review and staff interview, the agency failed to provide home health services as written in the physician ordered plan of care for four of seven patient records reviewed (Patient #1, #2, #3, and #7). This could affect all patients receiving services from the agency. The census was 38. Findings include: Review of the undated agency policy titled, “Staffing Issues,” revealed "the Clinical Manager, Case Manager and PT will oversee that all visits are scheduled according to the plan of Care. Whenever a scheduled visit cannot be rescheduled during the same Medicare week a missed visit note will be sent to the physician explaining the circumstances." 1. Review of Patient #1's medical record revealed a physician ordered plan of care dated 09/05/23 with orders for skilled nursing services 124 hours per week. Review of the skilled nurse visit sheets revealed 108 hours were provided the week of 09/24/23, 112 hours were provided the week of 10/01/23 and 92 hours were provided the week of 10/08/23. There was no documentation the patient's physician was notified that services were not provided as ordered. 2. Review of Patient #2's medical record revealed a physician ordered plan of care dated 09/14/23 with orders for home health aide (HHA) services eight hours per day. Review of the HHA visit sheets revealed from 06/17/23 to 10/07/23 the HHA provided six hours on Sundays and seven hours per day Monday through Saturday. There was no documentation the patient's physician was notified that services were not provided as ordered. 3. Review of Patient #3's medical record revealed a physician ordered plan of care dated 08/19/23 with orders for skilled nursing services 12 hours per day, seven days per week. Review of the skilled nurse visit sheets revealed the skilled nurse provided 12 hours per day for six days per week for the weeks of 08/20/23, 09/03/23, 09/10/23, 09/17/23, 09/24/23, 10/01/23 and 10/08/23. There was no documentation the patient's physician was notified that services were not provided as ordered. Interview on 10/18/23 at 1:52 PM with Staff A confirmed the services were not provided as ordered and the physician was not notified for Patient #1, #2, or #3. 4. Review of Patient #7's medical record revealed a physician ordered plan of care dated 01/16/23 with orders for home health aide (HHA) services six hours per week. Review of the HHA time sheets revealed the HHA provided 36 hours of care the week of 01/15/23, 35 hours the week of 01/22/23, 36 hours the week of 01/29/23, 36 hours the week of 02/05/23, 33 hours the week of 02/12/23 and 38 hours the week of 02/19/23. Interview on 10/18/23 at 3:38 PM with Staff C confirmed there was no physician orders for the additional hours HHA hours provided.

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 policy review, record review, and staff interview, the agency failed to ensure the individualized plan of care included goals identified by the home health agency and patient and discharge planning and failed to ensure the plan of care included the types of services to be provided for three of seven patients reviewed (Patients #1, #3 and #7). This could affect all patients receiving services from the agency. The census was 38. Findings include: Review of the agency policy titled, “Plan of Care – CMS #485 and Physician’s Orders,” revised 2015, revealed the Plan of Care is established in writing by the physician, agency staff, the patient and members of the patient’s family based on an evaluation of the patient’s immediate and long-term needs. The plan of Care includes the type of services required, specific procedures deemed essential for the health and safety of the patient, expected goals or outcomes to be achieved and a discharge plan. Care and services provided will be provided according to physician’s orders. The agency alerts the physician to any changes that suggest a need to alter the plan of care. 1. Review of Patient #1's medical record revealed the physician ordered plan of care dated 09/05/23 did not include any goals, discharge planning, or what skilled nursing services were to be provided. 2. Review of Patient #3's medical record revealed the physician ordered plan of care dated 08/19/23 did not include any goals or what skilled nursing services were to be provided. 3. Review of Patient #7's medical record revealed the physician ordered plan of care dated 01/16/23 did not include discharge planning or what home health aide services were to be provided. Interview on 10/18/23 at 4:03 PM with Staff A confirmed these findings.

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 record review, policy review, and staff interview, the agency failed to ensure the for patients receiving skilled nursing services, a registered nurse made an onsite visit to the patient's home no less frequently than every 14 days for three of three patients reviewed with skilled nursing services and home health aide services (Patient #2, #4 and #7). This could affect all patients receiving services from the agency. The total sample was seven patients. The census was 38. Findings include: Review of the agency policy titled, “Home Health Aide Supervision,” last revised 2015, revealed at least every 14 days the registered nurse makes an onsite home supervisory visit to assess relationships and determine whether goals are being met. 1. Review of Patient #2's medical record revealed a physician ordered plan of care dated 09/14/23 with orders for skilled nursing services two hours per week and home health aide (HHA) services eight hours per day. Review of the HHA supervisory visits revealed supervisory visits were made on 09/18/23 and 10/13/23, 25 days apart. 2. Review of Patient #4's medical record revealed a physician ordered plan of care dated 09/14/23 with orders for skilled nursing services one visit per week and HHA services six hours per day. Review of the HHA supervisory visits revealed supervisory visits were made on 09/01/23 and 10/04/23, 33 days apart. 3. Review of Patient #7's medical record revealed a physician ordered plan of care dated 01/16/23 with orders for skilled nursing services two visits per week and HHA services six hours per week. Review of the HHA supervisory visits revealed supervisory visits were made on 02/07/23 and 02/23/23, 16 days apart. Interview on 10/18/23 at 3:04 PM with Staff A confirmed the supervisory visits were conducted at least every 14 days.