Every finding on record at Alterna Care Inc.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 2/4/2021. The Facility was in compliance for the Condition, 42 CFR 484.62, Establishment of the Emergency Preparedness Program, for this survey.

A recertification survey was conducted in conjunction with a Focused Infection Control survey on 2/4/2021. The Agency was not in compliance with Conditions of Participation for Home Health Agencies, 484.45, Reporting OASIS Information; 484.60, Care Planning, Coordination, Quality of Care; 484.65, Quality Assessment and Performance Improvement; 484.70, Infection Control and Prevention; 484.105, Organization and Administration of Service; 484.110, Clinical Records; and the requirements for COVID-19. Therefore, the Agency is precluded from conducting aide training and/or competency evaluations for 24 months, effective 2/4/2021. This applies even if the agency is not currently conducting aide training and/or competency evaluation as evidenced by:

Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This CONDITION is not met as evidenced by: Based on document review and interview, it was determined that the Home Health Agency (HHA) failed to electronically report all OASIS data collected in accordance with regulations. This has the potential to affect all patients receiving care from the HHA with a current census of 29. Therefore, the Condition of Participation 42 CFR 484.45, Reporting of OASIS Information was not met, as evidenced by: Findings include: 1. The HHA failed to be able to demonstrate that the encoded OASIS data accurately reflected the patient's status at the time of the respective assessment(s). See G-0374. 2. The HHA failed to be able to demonstrate that the encoded OASIS data were transmitted in the required format. See G-0378.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on document review and interview, it was determined for 6 of 7 (Pt #1, Pt #2, Pt #3, Pt #4, Pt #5, Pt #6) patients, the Home Health Agency (HHA) failed to demonstrate that the encoded OASIS data accurately reflected the patient's status at the time of the respective assessment(s). This has the potential to affect all patients provided care by the HHA with a current census of 29, as evidenced by: Findings include: 1. As of 2/4/2021, the HHA was unable to provide access to the patients electronic OASIS records and had incomplete paper OASIS records to demonstrate that the encoded OASIS data accurately reflected the patient's status at the time of the respective assessment for the following patients: . Pt #1 Start of Care (SOC): 9/18/2020 Diagnosis: Surgical aftercare Pt #2 SOC: 8/20/2020 Diagnosis: Osteonecrosis Secondary to Trauma R femur Pt #3 SOC: 1/25/21 Diagnosis: Compression Fx T1 Pt #4 SOC: 1/11/19 Diagnosis: Neuromuscular Dysfunction Pt #5 SOC: 2/27/20 Diagnosis: Prostatic Hyperplasia Pt #6 SOC: 11/23/2020 Diagnosis: Anemia, multiple L Rib Fx 2. An interview was conducted with the clinical manager/owner (E#1) on 2/1/2021 at approximately 12:00 PM. E#1 stated "We have lost most of our patients". E #1 is an Registered Nurse and another part time nurse works two days a week. " My software is currently shut down for lack of payment. I am not able to update oasis until the bill is paid. I am waiting on covid assistance money to pay the bill".

OASIS data transmission format CFR(s): 484.45(c)(1) For all completed assessments, transmit OASIS data in a format that meets the requirements of paragraph (d) of this section. This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined for 3 of 7 (Pt #1, Pt #2, Pt #3) patients, the Home Health Agency (HHA) failed to ensure completed assessments OASIS data were transmitted in the required format. This has the potential to affect all patients provided care by the HHA with a current census of 29, as evidenced by: Findings include: 1. As of 2/4/21 at approximately 2:45 PM, the HHA was unable to demonstrate that completed assessments OASIS data was transmitted in the required format for the following patients Pt #1 Start of Care (SOC): 9/18/2020 Diagnosis: Surgical aftercare Pt #2 SOC: 8/20/2020 Diagnosis: Osteonecrosis Secondary to Trauma R femur Pt #3 SOC: 1/25/21 Diagnosis: Compression Fx T1 2. An interview was conducted with the clinical manager/owner (E#1) on 2/1/2021 at approximately 12:00 PM. "My software is currently shut down for lack of payment. I am not able to update oasis until the bill is paid. I am waiting on covid assistance money to pay the bill".

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on document review, interview and interview, it was determined the Agency failed to demonstrate current compliance of the ability to ensure the Plan of Care identified care and services necessary to meet the patient's needs, included physician orders, and was revised accordingly. Therefore, the Condition of Participation, 42 CFR 484.60, Care Planning, Coordination, Quality of Care, was NOT met. This has the potential to affect all potential patients who receive care by the Agency. Findings include: 1. The Agency failed to provide a current patient Plan of Care (POC). See G 0572

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 refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined that 3 of 7 (Pt #1, Pt #5, Pt #6) patient's records reviewed, the Agency failed to provide a current patient Plan of care (POC). This has the potential to affect all patients provided care by the HHA with a current census of 29, as evidenced by: Findings include: 1. On 2/1/2021 at 2:00 PM, the current patient list was submitted. Pt #1, Pt #5, and Pt #6 was listed as current patients. 2. Pt #1. SOC 9/18/2020. Primary Diagnosis: Surgical aftercare. The clinical record was reviewed 2/1/21 at approximately 10:45 AM. The most recent documentation of patient POC was certification date 11/17/2020 to 1/15/21. No current POC was provided. 3. Pt #5 Diagnosis: Prostatic Hyperplasia. SOC 2/27/2020. On 2/2/21, at approximately 2:30 PM, Pt #5 clinical record was reviewed. The record indicated POC certification period 10/24/2020 to 12/22/2020. No documentation of a current POC, transfer or discharge was submitted. 4. Pt #6 Diagnosis : Anemia, Multiple left rib fractures. SOC 11/23/2020. On 2/4/21 at approximately 10:00 AM, Pt #6 clinical record was reviewed. The record indicated POC certification 11/23/2020 to 1/21/2021 was completed. No documentation of a current POC, transfer or discharge was submitted. 5. In an interview with Clinical Manager/Owner (E#1) on 2/1/21 at 11:15 AM, a request for current care plans for Pt #1, Pt #5, and Pt #6 was requested. E#1 stated "My software is turned off for lack of payment. I do not have access to all of the POC's and my printer is almost out of ink".

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician orders. This STANDARD is not met as evidenced by: Based on record review and interview it was determined in 1 of 7 (Pt #7) records reviewed there was no physician notification documented when vital signs were out of parameters. This has the potential to affect all patients receiving care from this Agency with a current census of 29 active patients. Findings include: 1. Pt #7 SOC: 9/28/2020 Diagnosis: After Care Following Kidney Transplant. The record of Pt #7 was reviewed on 2/3/2021 at approximately 1:00 PM. The plan of care noted "notify physician of systolic blood pressure (top number of blood pressure reading)greater than 170...". The following dates lacked documentation to the physician of the high blood pressures: 10/22/2020-180/80, 10/29/2020-176/84, 11/16/2020-175/83 2. A request for "Vital Signs" policy was made on 2/3/2021 at approximately 2:00 PM. No documentation provided. 3. An interview was conducted with the clinical manger/owner (E #1) on 2/3/2021 at approximately 2:00 PM. E #1 stated "yes the blood pressures were out of the parameters and the physician was notified...I just didn't document it".

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician. This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined in 1 of 7 (Pt #6) patients' records reviewed, the Agency failed to ensure the Plan of Care (POC) included physician orders for services rendered. This has the potential to affect all patients who receive care by the HHA with a current patient census of 29. Findings include: 1. Pt #6 SOC: 11/23/2020 Diagnosis: Anemia and Multiple Fractured Ribs. The clinical record was reviewed on 2/2/2021 at approximately 10:00 AM. The last Plan of Care (POC) certification dated 11/23/2020 to 1/21/2021, indicated skilled nursing visits effective 11/23/2020; 1 m 1 (month) PRN 2. (as needed). The record lacked physician orders for registered nurse visit's on 12/22/2020 and 1/11/2021. 2. An interview was conducted with the clinical manager (E #1) on 2/2/2021 at approximately 11:00 AM. E #1 reviewed Pt #11's clinical record and stated "There are no physician orders for the 12/22/2020 and 1/11/2021 registered nurse visits. E #1 stated that a physician order should have been gotten for those two visits."

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on interview it was determine that the agency failed to provide documentation of the development, implementation, evaluation, and maintenance of an effective, ongoing, HHA-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program. Therefore the Condition of Participation, 42 CFR 484.65, Quality Assessment and Performance Improvement was not met, as evidenced by: Findings include: 1. The agency failed to provide documentation of a Quality Assessment and Performance Improvement (QAPI) program which: was capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care; as well as: failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. See G 0642

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interview it was determine that the agency failed to provide documentation of a Quality Assessment and Performance Improvement (QAPI) program which: was capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care; as well as: failed to measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This has the potential to affect all patients receiving care from the agency with a current census of 29, as evidenced by: Findings include: 1. On 2/1/2021 and 2/2/2021, a request for the QAPI program was submitted. No QAPI documentation was submitted by 2/4/2021. 2. During a interview with the clinical manager/owner (E #1) on 2/1/201 at 10:00 AM, E #1 stated that "For QAPI, I do chart audits" but would not say what E #1 audited the records for.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on document review and interview, it was determined that the agency failed to maintain and document an complete infection control program which has as its goal the prevention and control of infections and communicable diseases. Therefore, the Condition of Participation 484.70, Infection Control and Prevention, as evidenced by: Findings include: 1. The Agency failed to follow accepted standards of practice; including the use of standard precautions, to prevent the transmission of infections and communicable diseases. See G-0682. 2. The Agency failed to provide a screening process for patients and staff to promote early detection and management of COVID-19 signs and symptoms. See G-0684. 3. The Agency failed to ensure Infection Control/COVID-19 annual training was completed for employees who provide in home care to patients. See G-0686.

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: Based on observation, record review, and interview it was determined in 1 of 3 (Pt #3) home visits observed, the Agency failed to follow accepted standards of practice; including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This has the potential to affect all patients receiving care from this Agency with a current census of 29 active patients. Findings include: 1. A home visit with the Physical Therapy Assistant (E #3) was conducted on 2/2/2021 at approximately 2:00 PM. During the home visit the following was was noted: No "bag technique" was performed by E #3 (a barrier set under bag to prevent the possibility of cross contamination); After assessing the vital sings of Pt #3, E #3 did not perform cleaning or sanitization of the blood pressure cuff and; After completing care of patient, E #3 did not perform hand hygiene and did not remove gloves before leaving Pt #3's residence. 2. A request for home visit policy and infection control policy was made 2/3/2021 at approximately 11:00 AM. The Agency failed to provide the policies...stating "you can review them on my computer but I can't print them". 3. An interview was conducted with the agency manager/owner (E #1) on 2/3/2021 at approximately 2:00 PM. E #1 stated "The Physical Therapy Assistant should be performing hand hygiene and changing gloves along with cleaning equipment after contact with patient".

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview the Agency failed to provide a screening process for patients and staff to promote early detection and management of COVID-19 signs and symptoms. This has the potential to affect all patients receiving care from this Agency with a current census of 29 active patients. Findings include: 1. On 2/4/2021 at approximately 1:00 PM, the visit and temperature log was reviewed for the Physical Therapy Assistant (E #3) and Occupational Therapist (E #4). The log indicated temperatures of employees were checked twice per day. The log lacked evidence of the employee having symptoms or having any type of exposure to persons with COVID-19. 2. A log for the screening of staff and visitors was requested. The Agency lacked documentation that the screening of staff and/or visitors at the office was being completed. 3. An interview with the manager/owner (E #1) was conducted on 2/4/2021 at approximately 1:30 PM. E #1 stated "We do take temperatures twice daily, but only report if we are having symptoms. As far as at the office, no we are not screening normally because most of us have been working from home...and no we are not screening the patients before we go out on a home visit, we probably should be".

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure Infection Control/COVID-19 annual training was completed in 5 of 10 (E #1, E #2, E #4, E #6, E #9) employees who provide in home care to patients. This has the potential to affect all patients receiving care from this Agency with a current census of 29 active patients. Findings include: 1. The Infection Control training records were reviewed with E #1 on 2/3/2021 at approximately 9:00 AM. E #1, E #2, E #4, E #6, E #9 personnel records lacked annual infection control training. 2. The Infection Control policy was requested 2/3/2021 at approximately 10:00 AM. E #1 stated "You will have to read it on my computer...my printer is out of ink." 3. An interview was conducted with E #1 on 2/3/2021 at approximately 9:30 AM. E #1 stated "We have the training...it's just not documented as being done".

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on document review and interview it was determined that the Agency failed to organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. This has the potential to effect all patients being served by the HHA with a current census of 29. Therefore the Condition of Participation, 42 CFR 484.105, Organization and Administration of Services was not met, as evidenced by: Findings include: 1. The agency failed to have a current agency administrator. See G 0944 2. The agency failed to have a current agency administrator, who was appointed by and reports to the governing body. See G 0946 3. The agency failed to ensure that the parent reported to the appropriate entities that the two branch offices were closed. See G 0972

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on interview it was determined that the agency failed to have a current agency administrator. This has the potential to affect all patients served by the home health agency, with a current census of 29, as evidenced by: Findings include: 1. On 2/1/2021 at 2:00 PM, the Agency's licensure application dated 2/6/2020 was reviewed. The application listed the clinical manager/owner ( E #1) as the administrator. 2. On 2/1/2021 and 2/2/2021 a request for documentation of a organizational chart and and verification of a current administrator. No documentation of the organizational chart or evidence of a administrator was submitted. 3. During an interview with the clinical manager/owner (E #3) on 2/2/2021 at 10:00 AM, E #1 stated that "I am the clinical supervisor and the administrator resigned 1/7/2021 and I have a new administrator listed on a new licensure application. The paper work for the hiring of a administrator is not complete." E #1 provided no documentation that the agency had a new administrator.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on interview it was determined that the agency failed to have a current agency administrator, who was appointed by and reports to the governing body. This has the potential to affect all patients served by the home health agency, with a current census of 29, as evidenced by: Findings include: 1. On 2/1/2021 at 2:00 PM, the Agency's licensure application dated 2/6/2020 was reviewed. The application listed the clinical manager/owner ( E #1) as the administrator. 3. On 2/1/2021 and 2/2/2021 a request for documentation of a organizational chart and and verification of a current administrator. No documentation of the organizational chart or evidence of a administrator was submitted. 4. During an interview with the clinical manager/owner (E #3) on 2/2/2021 at 10:00 AM, E #1 stated that "I am the clinical supervisor and the administrator resigned 1/7/2021 and I have a new administrator listed on a new licensure application. The paper work for the hiring of a administrator is not complete." E #1 provided no documentation that the agency had a new administrator.

Report all branch locations to SA CFR(s): 484.105(d)(1) The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA's request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. This ELEMENT is not met as evidenced by: Based on document review and interview it was determined that the agency failed to ensure that the parent reported to the appropriate entities that the two branch offices were closed. Findings include: 1. On 2/1/2021 at 2:00 PM, the Agency's licensure application dated 2/6/2020 was reviewed. The application listed the branch offices as: 1515 W Walnut Bld 13 Jacksonville and 913 W Walnut Litchfield. 2. On 2/1/2021 at 2:15 PM, the brochure titled "Alterna Care" stated that the agency had a branch office at 1515 W Walnut Bld 13 Jacksonville. 3. During an interview with the clinical manager/owner (E #1) conducted on 2/1/2021 at 2:45 PM, E #1 stated that the branches offices are closed and has no staff, supplies or records at those locations. E #1 stated that "I was hoping to re-open them in the future. The branches were last open in 2019. I did not notify anyone that the two branches were closed."

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on document review and interview, it was determined the Home Health Agency (HHA) failed to ensure that the clinical records were protected and available and retrievable. This has the potential to effect all patients being served by the HHA with a current census of 29. Therefore the Condition of Participation, 42 CFR 484.110, Clinical Records was not met, as evidenced by: Findings include: 1. The agency failed to ensure that clinical records were safeguarded against loss or unauthorized use. See G 1028 2. The agency failed to ensure that clinical records were available and retrievable. See G 1030

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on record review and interview it was determined that the agency failed to ensure that clinical records were safeguarded against loss or unauthorized use. This has the potential to affect all patients receiving care with a current census of 29, as evidenced by: Findings include: 1. On 2/1/2021 at 9:30 AM, a request for patient medical records was submitted. 2. During an interview with the clinical manager/owner (E #1) conducted on 2/1/2021 at 10:00 AM, E #1 stated that all of the patient records were at E #1's house and E #1 could not retrieve them today. "We do not have access to the electronic medical records system because we have not paid the bill. Some of the records are paper and some are electronic, but we can not access the electronic part of the records. "

Retrieval of records CFR(s): 484.110(e) Standard: Retrieval of clinical records. A patient's clinical record (whether hard copy or electronic form) must be made available to a patient, free of charge, upon request at the next home visit, or within 4 business days (whichever comes first). This STANDARD is not met as evidenced by: Based on record review and interview it was determined that the agency failed to ensure that clinical records were available and retrievable. This has the potential to affect all patients receiving care with a current census of 29, as evidenced by: Findings include: 1. On 2/1/2021 at 9:30 AM, a request for patient medical records was submitted. 2. During an interview with the clinical manager/owner (E #1) conducted on 2/1/2021 at 10:00 AM, E #1 stated that all of the patient records were at E #1's house and E #1 could not retrieve them today. "We do not have access to the electronic medical records system because we have not paid the bill. Some of the records are paper and some are electronic, but we can not access the electronic part of the records. "