Every finding on record at Alphazeta Healthcare Services, LLC

The Emergency Preparedness requirements were evaluated in conjunction with the recertification survey on 2/26/25. Standard level deficiencies were cited. Abbreviations: Pts. = Patients PM = afternoon/evening

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 a review of the Agency’s Emergency Preparedness plan and staff interview, it was determined that the Agency failed to conduct the required testing of its Emergency Preparedness plan. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Emergency Preparedness plan was reviewed on 2/24/25 and 2/25/25. The plan lacked documentation that the Agency conducted or participated in a full-scale exercise, facility-based exercise, or activated the Agency's Emergency Preparedness plan in 2021, 2022, 2023, 2024, and 2025 (as of 2/25/25). 2. During a staff interview with the Administrator, Director of Nursing, Assistant Director of Nursing, and the Office Manager (administrative staff) on 2/25/25 at 1:57 PM, the Assistant Director of Nursing confirmed the Agency failed to conduct the required testing of its Emergency Preparedness plan.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 2/26/25. Standard level deficiencies were cited. Abbreviations: # = number % = percent SN = Skilled Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients OASIS = Outcome and Assessment Information Set

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on a review of the Error Summary report and staff interviews, it was determined that in the last 12 months, the Agency failed to submit 38 of 392 assessments timely, resulting in a warning. Findings include: 1. The Error Summary report for 2/1/24 to 1/31/25 was reviewed on 2/24/25. The report included error # -3330 for 38 of 392 (9.69 %) OASIS reports that were submitted more than 30 days after the assessments were completed. 2. The Administrator, Director of Nursing, Assistant Director of Nursing, and the Office Manager were interviewed on 2/25/25 at 1:57 PM. During this interview, the Office Manager stated she is responsible for OASIS submissions and confirmed that the errors occurred.

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 a review of clinical records and staff interview, it was determined that in 1 of 2 (Pt. #7) closed clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the transfer and/or discharge summary. Findings include: 1. Pt. #7 was admitted to home health services on 5/13/23 with the diagnosis of Heart Failure, Unspecified. The closed clinical record was reviewed on 2/25/25. The closed clinical record contained a Transfer Summary completed by the SN on 3/31/24. The record lacked documentation that a copy of the summary was sent to the Physician. 2. During a staff interview with the Administrator, Director of Nursing, Assistant Director of Nursing, and the Office Manager on 2/25/25 at 1:57 PM, the Assistant Director of Nursing and Office Manager confirmed the Agency failed to send a copy of the Transfer Summary to the patients' Physicians.

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), §485.625(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: A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to have a communication plan that included the required names and contact information. 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 12/7//21 at 11:15 AM. The plan lacked a communication plan that meets the following requirements: Names and contact information for entities providing service under arrangement, Pt. Physicians, and Volunteers. 2. During an interview with the Assistant Administrator, Director of Nursing, and Director of Clinical Services on 12/8/21 at 10:15 AM, the Administrator confirmed the above finding.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: SOC = Start of care POC = Plan of care Pt./Pts. = Patient/patients AM = Morning PM = Afternoon/Evening SN = Skilled Nurse RN = Registered Nurse CNA = Certified Nursing Assistant COVID-19 = Corona Virus Disease 2019 mg = milligrams mcg = micrograms tab = tablet inh = inhalation PT = Physical Therapist E = Employee

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: A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to ensure an RN performed the initial assessment within 48 hours of the Physician referral for Home Health Care services. This was found in 5 of 7 (Pts. #2, 4, 5, 6, and 7) clinical records reviewed. 3. Pt #5. SOC 9/10/21. Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 12/6/21 at 2:00 PM. The record included the SOC comprehensive assessment dated 9/10/21 which included, the referral date of 8/18/21. The record lacked a Physician ordered SOC date or documentation of discharge date from an inpatient facility. As of 12/8/21, the Agency failed to start service within 48 hours of the referral date. 4. Pt #6. SOC 5/21/21. Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 12/7/21 at 9:00 AM. The record included the SOC comprehensive assessment dated 5/21/21 which included, the referral date of 5/11/21. The record lacked a Physician ordered SOC date or documentation of discharge date from an inpatient facility. As of 12/8/21, the Agency failed to start service within 48 hours of the referral date. 5. Pt #7. SOC 7/28/21. Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 12/7/21 at 9:45 AM. The record included the SOC comprehensive assessment dated 7/28/21 which included, the referral date of 6/2/21. The record lacked a Physician ordered SOC date or documentation of discharge date from an inpatient facility. As of 12/8/21, the Agency failed to start service within 48 hours of the referral date. 6. The Agency policy titled "Referral and Acceptance of Patients/Clients" was reviewed on 12/8/21 at 12:30 PM. Procedure for acceptance of patients “The Agency Supervisor assigns clinical Agency staff to conduct an initial assessment of eligibility for services within 48 hours of acceptance of referral information and/ or discharge from the referring facility.” 7. During an interview with the Administrator, Director of Nursing and Director of Clinical Services on 12/8/201 at 10:15 AM to 11:15 AM, the Administrative Staff confirmed the above findings. Findings include: 1. Pt. #2. SOC 9/24/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 12/6/21 at 12:30 PM. The record included a Physician referral for home health SN services, faxed to the Agency on 9/6/21. The record also contained the initial SOC assessment performed by the RN, dated 9/24/21, 18 days after the Physician referral. The record lacked documentation of an inpatient facility stay or Physician ordered SOC date. 2. Pt. #4. SOC 10/26/21. Primary Diagnosis: Chronic Obstructive Pulmonary Disease, Unspecified. The clinical record was reviewed on 12/6/21 at 1:20 PM. The record included a Physician referral for home health SN and CNA services, faxed to the Agency on 10/16/21. The record also contained the initial SOC assessment performed by the RN, dated 10/26/21, 10 days after the Physician referral. The record lacked documentation of an inpatient facility stay or Physician ordered SOC date.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: A. Based on review of clinical records, Agency policy and staff interviews, it was determined the Agency failed to ensure Influenza/Pneumococcal immunization screening was conducted at the time of Start of Care. This was found in 3 of 7 (Pts. #2, 3, and 5) clinical records reviewed. Findings include: 1. Pt #2. SOC 9/24/21. Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 12/6/21 at 12:30 PM. The record lacked documentation of Pneumococcal Pneumonia vaccination status. The record also lacked documentation that RN coordinated care with the physician's office regarding vaccination status. 2. Pt #3. SOC 5/27/21. Diagnosis: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy. The clinical record was reviewed on 12/6/21 at 1:00 PM. The record lacked documentation of the Influenza and Pneumococcal Pneumonia vaccination status. The record also lacked documentation that RN coordinated care with the physician's office regarding vaccination status. 3. Pt #5. SOC 9/10/21. Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 12/6/21 at 2:00 PM. The record lacked documentation of the Influenza and Pneumococcal Pneumonia vaccination status. The record also lacked documentation that RN coordinated care with the physician's office regarding vaccination status. 4. The Agency policy titled, "Vaccinations” was reviewed on 12/8/21 at 12:00 PM. The policy included under Influenza “Individual patient/client record entries identifying the assessment for the need of vaccination; date of offer of referral; patient/client response; administration, contraindication, or refusal; and any follow up activities. Standardized check off form recording patient/client specific information, including the assessment for the need of vaccination; date of offer or referral; patient/client response; administration, contraindication, or refusal; and any follow-up activities.” 5. During an interview with the Administrator, Director of Nursing and Director of Clinical Services on 12/8/201 at 10:15 AM to 11:15 AM, the Administrative Staff confirmed the above findings.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure Pts. are screened for COVID-19, prior to providing Pt. care and services. This was found in 3 of 7 (Pts. #6, 7, and 1) clinical records reviewed. 3. Pt. #1. SOC 11/5/21. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 12/6/21 at 2:20 PM. The record contained documentation the PT provided service on 11/10/21, 11/11/21, 11/16/21, 11/19/21, and 11/23/21. The record lacked documentation the PT screened the Pt. for signs and symptoms of COVID-19 prior to these visits. 4. During an interview on 12/8/21 at 10:15 AM with the Administrator, Director of Nursing, and Director of Clinical Services, the Director of Nursing stated all clinicians must screen Pts. for signs and symptoms of COVID-19 prior to home visits, and document the results of these screenings in the Patient’s clinical record. Findings include: 1. Pt #6. SOC 5/21/21. Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 12/7/21 at 9:00 AM. The record lacked documentation the PT screened Pt. for signs and symptoms of COVID-19, prior to the visits on 6/4/21, 6/8/21, 6/11/21, 6/16/21 and 6/18/21. 2. Pt #7. SOC 7/28/21. Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 12/7/21 at 9:45 AM. The record lacked documentation the PT screened the Pt. for signs and symptoms of COVID-19, prior to the visit on 8/4/21.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: A. Based on clinical record review, observations and interviews during home visits, and staff interview, it was determined the Agency failed to ensure the medications listed in the clinical record were complete and accurate. This was found in 2 of 7 (Pts. #1 and 2) clinical records reviewed. Findings include: 1. Pt. #1. SOC 11/5/21. Primary Diagnosis: Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 12/6/21 at 2:20 PM. The record included a Medication Profile, printed on 12/6/21. A home visit was conducted on 12/7/21 at 9:30 AM, along with E #6. During the home visit, the Patient's medications were reviewed, along with the Patient’s Medication Profile. The Pt. provided a bottle of Hydralazine 100 mg tablets, with the direction on its label to take one tablet twice a day. The Pt. stated this was the dose taken “since I was in the hospital, more than a month.” The Medication Profile contained “Hydralazine 100 mg 1 tab three times daily by mouth.” The Medication profile listed “Omeprazole 20 mg 1 tab daily 30 minutes before breakfast by mouth.” The Pt. did not have this medication, and stated it was discontinued “while I was hospitalized, more than a month ago.” The Pt. also presented a box of Bisacodyl 5 mg tablets, stating she takes one as needed “for a long time.” Bisacodyl was not included on the Medication Profile. The Medication Profile was not complete and accurate. 2. Pt. #2. SOC 9/24/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 12/6/21 at 12:30 PM. The record included a Medication Profile, printed on 12/6/21. A home visit was conducted on 12/7/21 at 3:00 PM, along with E #1. During the home visit, the Patient's medications were reviewed, along with the Patient’s Medication Profile. The Pt. provided a bottle of Amlodipine 2.5 mg, with the direction on its label to take one tablet daily. The Pt. reported taking this medication “for at least 6 months.” Amlodipine was not listed on the Patient’s Medication Profile. The Pt. also provided a bottle of Meclizine 25 mg tablets, with the direction on its label to take one tablet 3 times a day, as needed. The Pt. confirmed this was the dose the Pt. was taking, “for at least 6 months.” The Medication Profile contained “Meclizine 25 mg 1 tablet twice a day as needed for dizziness by mouth.” The Medication Profile also included “Aspirin 1 tab daily by mouth.” The Pt. did not have a bottle of Aspirin, and stated the Physician told her to stop taking it “at least a month ago.” The Medication Profile also contained “Fluticasone 50 mcg/inh nasal spray 1 spray daily to each nostril.” The Pt. did not have this nasal spray, and stated she hasn’t been using it “for quite a while.” The Medication Profile was not complete and accurate. 3. The Agency policy titled “Medication Profile” was reviewed on 12/8/21 at 9:45 AM. The policy required: “…Purpose: To ensure all patients/clients have a current list of medications.…Medication Profiles must be updated at least every 60 days, and whenever there is a change in the medication regime…” 4. During an interview on 12/8/21 at 10:15 AM with the Administrator, Director of Nursing, and Director of Clinical Services, the Director of Nursing stated the Nurse or Skilled Therapist should reconcile the Patient’s medications with the Medication Profile during each home visit. If the Pt. reports a new or discontinued medication, or a change in dosage, the Nurse/Skilled Therapist should obtain a Physician’s order, and the Medication Profile should then be updated accordingly.