Every finding on record at American Home Care, LLC

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: A. Based on a review of the Agency’s Emergency Preparedness plan and staff interview, it was determined the Agency failed to ensure the plan included a process for communicating with emergency preparedness officials for the purpose of Pt. evacuation. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness plan last updated in “2021” was reviewed on 3/8/22 at 2:20 PM. The plan lacked a procedure or method for contacting State and local emergency preparedness officials to inform them of Pts. required to vacate their home, in the event of an emergency or disaster. 2. During an interview with the Director of Clinical Services/Clinical Director on 3/9/22 at 2:55 PM, the Clinical Director confirmed the Agency lacked a process regarding communication with emergency preparedness officials for the purpose of Pt. evacuation.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA 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:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: A. Based on a review of the Agency’s Emergency Preparedness plan and staff interview, it was determined the Agency failed to ensure the plan included a policy and process for contacting employees’ on-duty and Pts. in the event of an emergency. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness plan last updated in “2021” was reviewed on 3/8/22 at 2:20 PM. The plan lacked a policy and procedure for connecting with staff actively working and Pts. in the event of an emergency or disaster. 2. During an interview with the Director of Clinical Services/Clinical Director on 3/9/22 at 2:55 PM, the Clinical Director confirmed the Agency lacked a policy and process for contacting employees’ on-duty and Pts. in the event of an emergency.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. 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 the Agency failed to establish a policy and procedure to forward necessary Pt. information in a secure manner, in the event of an emergency. This has the potential to affect all Pts. that receive service from the Agency. Findings include: 1. The Emergency Preparedness plan last updated in “2021” was reviewed on 3/8/22 at 2:20 PM. The plan lacked a policy and process for ensuring Pt. medical documents are kept confidential, secure and available, in the event of an emergency. 2. During an interview with the Director of Clinical Services/Clinical Director on 3/9/22 at 2:55 PM, the Clinical Director confirmed the Agency lacked a policy and procedure to forward necessary Pt. information in a secure manner in the event of an emergency.

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 the Agency failed to ensure the communication plan was accurate and current. This has the potential to affect all Pts. receiving service from the Agency. Findings include: 1. The Emergency Preparedness plan last updated in “2021” was reviewed on 3/8/22 at 2:20 PM. The plan contained 2 undated “Pyramid Phone” communication plans, and 2 Employee lists both dated 01/25/21 which lacked active staff (Employees #1, 5, 6 and 8) and contained multiple former staff. The communication plan was inaccurate and out-of-date. 2. During an interview with the Director of Clinical Services/Clinical Director on 3/9/22 at 2:55 PM, the Clinical Director confirmed the Emergency Preparedness communication plan was inaccurate and lacked current staff.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. 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 the Agency failed to establish a plan that include an alternate form of communication in the event of an emergency. This has the potential to affect all Pts. receiving service from the Agency. Findings include: 1. The Emergency Preparedness plan last updated in “2021” was reviewed on 3/8/22 at 2:20 PM. The plan lacked documentation of an alternate source of communicating with staff, Federal, State, regional and local emergency agencies, during an emergency or disaster. 2. During an interview with the Director of Clinical Services/Clinical Director on 3/9/22 at 2:55 PM, the Clinical Director confirmed the Agency lack a plan that include an alternate form of communication in the event of an emergency.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: A. Based on the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to ensure the plan include a process for sharing Pt. information to ensure continuity of care. This has the potential to affect all Pts. receiving service from the Agency. Findings include: 1. On 3/8/22 at 2:20 PM, the Agency’s Emergency Preparedness plan last updated in “2021” was reviewed. The Plan lacked documentation regarding a process of sharing Pt. clinical information to other health providers, making sure Pt. care is provided in the event of an emergency. 2. During an interview with the Director of Clinical Services/Clinical Director on 3/9/22 at 2:55 PM, the Clinical Director confirmed the Agency lacked a process for sharing Pt. information to ensure continuity of care.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: A. Based on review of the Agency's Emergency Preparedness plan, Team Meetings binder, staff/employee personnel files, Agency policy and staff interview, it was determined the Agency failed to conduct staff/employee training relative to the Agency's Emergency Preparedness Plan. This was found in 3 of 3 (Employee #1, 3 and 4) direct employee personnel files reviewed. Findings include: 1. On 3/8/22 at 2:20 PM, the Emergency Preparedness plan last updated in “2021” was reviewed. As of 3/8/22, the plan lacked documentation that staff received training of the Agency’s Emergency Preparedness plan in 2020 and 2021. 2. The Agency's “Team Meetings” binder was reviewed on 3/8/22 at 10:00 AM. As of 3/8/22, the binder lacked documentation the staff received training on the Agency’s Emergency Preparedness plan in 2020 and 2021. 3. On 3/9/22 at 3:30 PM with the Director of Clinical Services/Clinical Director, the personnel files of direct employees (Employee #1, 3 and 4) were reviewed and lacked documentation the staff received training on the Agency’s Emergency Preparedness plan in 2020 and 2021. 4. The Agency policy titled, “Emergency Management Plan” was reviewed on 3/8/22 at 2:30 PM. The policy included: “…12. Organization leadership will provide… education of all personnel regarding participation in the emergency management plan. Education will be provided during orientation and annually…” 5. During an interview with the Director of Clinical Services/Clinical Director on 3/9/22 at 2:55 PM, the Clinical Director confirmed the Agency failed to conduct staff/employee training relative to the Agency's Emergency Preparedness plan in 2020 and 2021.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: x = times w = week # = number AM = morning SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care PM = afternoon/evening Pt./ Pts. = Patient/Patients ST = Speech Therapy/Therapist PT = Physical Therapy/Therapist HHA / HHAide = Home Health Aide

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: A. Based on review of the Agency's Pt. admission folder, clinical record review, observation during home visits and staff interview, it was determined the Agency failed to provide Pts. information regarding the Agency's transfer and discharge policies. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Agency's admission folder was reviewed on 3/7/22 at 11:15 AM and lacked documentation pertaining to the Agency's transfer and discharge policies. 2. The clinical records of the following Pts. were reviewed from 3/8/22 at 10:00 AM to 3/9/22 at 1:15 PM: Pt. #1. SOC 1/19/22. Pt. #2. SOC 7/13/20. Pt. #3. SOC 2/8/22. Pt. #4. SOC 2/7/22. Pt. #5. SOC 12/6/21. Pt. #6. SOC 3/19/21. Pt. #7. SOC 6/4/21. The records lacked documentation that the Agency provided Pts. information of the Agency’s transfer and discharge policies. 3. The following home visits were conducted: Pt. #1. SOC 1/19/22. Home visit on 3/8/22 at 9:00 AM Pt. #2. SOC 7/13/20. Home visit on 3/8/22 at 11:00 AM Pt. #3. SOC 2/8/22. Home visit on 3/7/22 at 3:10 PM During the home visits, the Pt. admission folders of Pts #1 and 3 were observed, and lacked documentation of the Agency's transfer and discharge policies. During the home visit of Pt. #2, the caregiver was unable to locate the Pt. admission folder. 4. During an interview with the Director of Clinical Services/Clinical Director on 3/9/22 at 3:30 PM, the Clinical Director was not aware that the Agency was required to provide information regarding the Agency's transfer and discharge policies. During the same interview, the Clinical Director confirmed the above findings.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: A. Based on Agency policy and staff interview, it was determined the Agency failed to maintain documentation of Pt. complaints. This has the ability to affect all services provided by the Agency. Findings include: 1. The Agency policy titled, “Complain/Grievance Process” was reviewed on 3/10/22 at 11:50 AM. The policy included: “…10. All complaints will be logged, tracked, and filed in the performance improvement office…” 2. During the entrance interview with the Director of Clinical Services/ Clinical Director on 3/7/22 at 10:45 AM, a request was made to review the Agency’s Pt. complaint log. On 3/7/22 at 4:10 PM, the Clinical Director stated “I cannot find it”. 3. On 3/8/22 at 3:40 PM, a second request was made to review the Agency’s Pt. complaint log. As of 3/8/22, the Director of Clinical Services/ Clinical Director confirmed the Agency was unable to locate the Pt. complaint log.

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: A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure the initial POC was reviewed and signed by the Physician within 30 days, and staff provide service as indicated on the POC. This was found in 4 of 7 (Pts. #1, 4, 2 and 5) clinical records reviewed. 3. Pt. #2. SOC 7/13/20. Primary Diagnosis: Acute on Chronic Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 3/8/22 at 10:00 AM. The record contained the POC for the certification period of 1/4/22 to 3/4/22. The POC included the Physician’s order: “HHA Frequency: 1-2w9.” The record lacked documentation the HHA provided service on the weeks of: 2/6/22 to 2/12/22, 2/13/22 to 2/19/22, 2/20/22 to 2/26/22, and 2/27/22 to 3/4/22. 4. Pt. #5. SOC 12/6/21. Primary Diagnosis: Chronic Obstructive Pulmonary Disease with Acute Exacerbation. The clinical record was reviewed on 3/8/22 at 11:20 AM. The record included the POC for the certification period of 12/6/21 to 2/3/22. As of 3/8/22, the POC lacked the Physician's signature (92 days from the SOC), verifying the Physician reviewed and approved the initial POC. 5. The Agency policy titled, “Care/Service Coordination” was reviewed on 3/10/22 at 9:20 AM. The policy required: “…Visits should be provided at the frequency as ordered by the Physician. Missed visits should be documented and the Physician notified of the missed visit…” 6. The Agency policy titled, “Physician Participation in the Plan of Care” was reviewed on 3/10/22 at 9:30 AM. The policy required: “…The Attending Physician will sign the plan of care/treatment within 30 days of the start of care…” 7. During interviews with the Director of Clinical Services/Clinical Manager on 3/9/22 at 1:10 PM and 3:30 PM, and on 3/10/22 at 10:30 AM, the above findings were confirmed. Findings include: 1. Pt. #1. SOC 1/19/22. Primary Diagnosis: Non-pressure Chronic Ulcer Other Part of Lower Leg with Fat Layer Exposed. The clinical record was reviewed on 3/8/22 at 2:55 PM. The record contained the initial POC effective 1/19/22. As of 3/8/22, the POC lacked the Physician's signature (50 days from the SOC), verifying the Physician reviewed and approved the initial POC. 2. Pt. #4. SOC 2/7/22. Primary Diagnosis: Fracture of Unspecified Part of Neck of Left Femur, Subsequent For Closed Fracture with Routine Healing. The clinical record was reviewed on 3/8/22 at 2:12 PM. The record contained the initial POC effective 2/7/22 requiring “1-2w2, 1w1…Physical Therapy for: Strengthening…to improve transfers, ambulation, and stairs; Home Exercise Program Instruction…” As of 3/8/22, the record lacked documentation the PT provided any service after 2/9/22.

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 clinical record review and staff interview, it was determined the Agency failed to ensure Pts. were screened at the SOC for the status of the Influenza and/or Pneumococcal Pneumonia vaccines. This was found in 4 of 7 (Pts. #2, 6, 3, and 7) clinical records reviewed. 3. Pt. #3. SOC 2/8/22. Diagnoses: Acute and Chronic Respiratory Failure with Hypoxia and Asymptomatic Human Immunodeficiency Virus Infection Status. The clinical record was reviewed on 3/9/22 at 1:15 PM. As of 3/9/22, the record lacked documentation the staff inquired whether the Pt. required, requested, received and/or declined the Influenza vaccine for 2022. 4. Pt. #7. SOC 6/4/21. Primary Diagnosis: Infection and Inflammatory Reaction due to Other Cardiac and Vascular Devices, Implant and Grafts, Subsequent Encounter. The clinical record was reviewed on 3/8/22 at 10:15 AM. As of 3/8/22, the record lacked documentation that during the SOC, the staff inquired whether the Pt. required, requested, received and/or declined the Influenza and Pneumococcal vaccines for 2021. 5. The Agency’s policy titled, “Initial and Comprehensive Assessment” was reviewed on 3/9/22 at 10:00 AM. The policy included, “…3. During the initial and comprehensive patient assessment, all baseline data to be used in measuring the patient’s progress towards goals and other relevant information will be documented in the patient’s clinical record, including… Immunizations, when appropriate.” 6. During the entrance interview on 3/7/22 at 10:45 AM, the Director of Clinical Services/Clinical Director stated staff are required to inquire about the patient’s Influenza and Pneumococcal Pneumonia status at the “SOC and recertification”, and this information is documented “in the comprehensive assessment.” 7. During an interview with the Director of Clinical Services/Clinical Director on 3/9/22 at 3:30 PM, the Clinical Director confirmed the Agency lacked a policy for inquiring the patient’s Influenza and Pneumococcal Pneumonia status. During the same interview, the Clinical Director confirmed the above findings. Findings include: 1. Pt. #2. SOC 7/13/20. Primary Diagnosis: Acute on Chronic Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 3/8/22 at 10:00 AM. The record lacked documentation the Pt. was screened at the SOC for the status of the Influenza vaccine. 2. Pt. #6. SOC 3/19/21. Primary Diagnosis: Cerebral Infarction, Unspecified. The clinical record was reviewed on 3/8/22 at 1:00 PM. The record lacked documentation the Pt. was screened at the SOC for the status of the Pneumococcal Pneumonia vaccine.

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 observation during a home visit, review of Agency policy and staff interview, it was determined the Agency failed to ensure staff clean equipment, as required by the Agency. This was found in 1 of 3 (Pt. #3) home visits conducted. Findings include: 1. Pt. #3. SOC 2/8/22. Diagnoses: Acute and Chronic Respiratory Failure with Hypoxia and Asymptomatic Human Immunodeficiency Virus Infection Status. A home visit was conducted with Employee #6 on 3/7/22 at 3:10 PM. During the home visit, observed Employee #6 remove reusable equipment, a blood pressure cuff and stethoscope from their therapy bag, then used the items on Pt. #3. After using the equipment, Employee #6 cleaned the equipment with wipes labeled: “…multi-purpose antibacterial wet wipes”. The label also included, “Use for hand washing to decrease bacteria on the skin when water is not available” Employee #6 failed to disinfect equipment, as required by the Agency’s policy. 2. The policy titled, “Bag Technique” was reviewed on 3/9/22 at 9:30 AM. The policy required: “…5. When the visit is completed, reusable equipment will be cleaned using alcohol, soap and water, or other appropriate solution… equipment and supplies will be returned to the bag…” 3. During an interview with the Director of Clinical Services/Clinical Director on 3/9/22 at 3:30 PM, the Clinical Director stated staff are required to clean reusable equipment with alcohol or disinfectant wipes. During the same interview, the Clinical Director confirmed Employee #6 failed to clean reusable equipment after Pt. use, as required by the Agency.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: A. Based on clinical record review, Agency policy review and staff interview, it was determined the Agency failed to ensure the Home Health Aide provide service as required in the care plan. This was found in 1 of 1 (Pt. #7) clinical records reviewed, wherein Home Health Aide services were provided. Findings include: 1. Pt. #7. SOC 6/4/21. Primary Diagnosis: Infection and Inflammatory Reaction due to Other Cardiac and Vascular Devices, Implant and Grafts, Subsequent Encounter. The clinical record was reviewed on 3/8/22 at 10:15 AM. The POC for the certification period of 6/4/21 to 8/2/21 required the HHAide to provide service. The “HHAide Care Plan” completed by the SN and dated 6/4/21 required, “Weight Every visit”. The HHAide visit notes dated 6/8/21, 6/23/21 and 6/28/21 lacked documentation the HHA weighed the Pt. 2. During an interview with the Director of Clinical Services/Clinical Director on 3/9/22 at 3:30 PM, the Clinical Director confirmed the HHAide failed to weigh the Pt.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; 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 Pt. visit notes were incorporated into the Patient’s clinical record in a timely manner. This was found in 2 of 7 (Pts. #2 and 6) clinical records reviewed. Findings include: 1. Pt. #2. SOC 7/13/20. Primary Diagnosis: Acute on Chronic Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 3/8/22 at 10:00 AM. The record included documentation the HHA provided service on 1/14/22, 1/28/22, 2/1/22, and 2/4/22; however, these HHA visit notes were left blank. 2. Pt. #6. SOC 3/19/21. Primary Diagnosis: Cerebral Infarction, Unspecified. The clinical record was reviewed on 3/8/22 at 1:00 PM. The record included documentation the ST provided service on 4/29/21; however, the record lacked documentation of the assessment and treatment provided during this ST visit. 3. The Agency policy titled “Clinical Record Review” was reviewed on 3/10/22 at 9:40 AM. The policy required: “…Each clinical record will be reviewed on an ongoing basis by the Clinical Supervisor, Performance Improvement Coordinator, Clinical Director, or designees for: The timeliness of entries into the clinical record…The completeness of clinical records…” 4. The Agency policy titled Contents of Clinical Record” was reviewed on 3/10/22 at 9:50 AM. The policy required: “…The following information will be available in the clinical record for patients receiving skilled care: Signed and dated progress notes for each discipline…Documentation of the assessment data collected, actions and interventions performed, and patient response to care provided…” 5. During an interview with the Director of Clinical Services/Clinical Manager on 3/9/22 at 1:10 PM, the above findings were confirmed. The Director of Clinical Services/Clinical Manager stated all visit notes should be completed and entered into the patient’s clinical record within 7 days.