Every finding on record at Amy Home Health Services Inc

Purpose of visit: Recertification survey Entrance Date: 10/20/2021 at 11:20 AM with the Administrator. Agency Census: 19 Licensed and Certified Home Health -15 Licensed Home Health - 0 Personal Assistance Services - 4 Exit Date: 10/26/2021 at 3:15 PM with the Administrator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Abbreviations: COVID-19 – Coronavirus disease 2019 HIV – Human immunodeficiency viruses AIDS -Acquired immune deficiency syndrome

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness plan that was reviewed and updated every 2 years. The agency failed to update the risk plan to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. The agency risk assessment failed to identify the pandemic COVID-19 as a risk. The agency also failed to update the risk assessment to elevate the risks of winter storms and power outages after the community wide weather event in February 2021. This failure meant the agency staff and patients were potentially subjected to harm if the agency failed to take all required actions to mitigate these risks. Review of the agency emergency preparedness program documents revealed a document titled: “All Hazards Community/Agency Based Risk Assessment for Potential Disasters” completed by the Administrator and dated 04/09/2021. The risk assessment form section E. titled: “Epidemic or Pandemic” listed Influenza, HIV/AIDS, Ebola, and Zika Virus as types of disasters. The risk assessment failed to identify the COVID-19 pandemic. The risk assessment documented the risk for winter weather and power outages as “low.” The ratings for these areas were the same as the annual reviews dated 2020, 2019 and 2018. The risk assessments did not reflect the risks after the community wide winter weather and power outage events that occurred in February 2021 during the agency’s 04/2021 review of the risk assessment. An interview was conducted with the Administrator on 10/26/2021 at 2:00 PM. The surveyor reviewed the findings from the review of the agency Emergency Preparedness documents including the lack of identification of the COVID-19 pandemic as a risk for the agency, clients, and patients. The Administrator stated: “COVID should be there and the winter storm.” Agency policy titled: “Emergency Preparedness and Response Plan EC.8” read in part: The Agency will have a written emergency preparedness and response plan that comprehensively describes identification of potential disasters, including infectious diseases …The plan will be based on and include a documented all-hazards risk assessment that identifies the disasters from natural and man-made causes that are likely to occur in the Agency’s services area and/or facility…”

Purpose of visit: Recertification survey Entrance Date: 10/20/2021 at 11:20 AM with the Administrator. Agency Census: 19 Licensed and Certified Home Health -15 Licensed Home Health - 0 Personal Assistance Services - 4 Exit Date: 10/26/2021 at 3:15 PM with the Administrator. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations: PAS - Personal Assistance Services QAPI – Quality Assurance Performance Improvement DADS- Department of Aging and Disability Services HHSC – Health and Human Service Commission TULIP- Texas uniform licensure information portal COVID-19 – Coronavirus disease 2019 HIV – Human immunodeficiency viruses AIDS -Acquired immune deficiency syndrome DON- Director of Nurses ABN – Advance Beneficiary Notice QIO – Quality Improvement Organization NOMNC- Notice of Medicare Non-Coverage

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Previously cited during the survey dated 05/10/2018 Based on record review and interviews the agency failed to provide the required Notice of Medicare Non-Coverage at least two days prior to the discharge date for one (Patient 1) of one discharged patient records reviewed, whose reason for discharge was “goals met”. The agency also failed to include the correct telephone number for an immediate appeal regarding the discharge decision by the agency for Patient 1. The agency provided an incorrect phone number to contact the QIO. The agency should have included the QIO (KEPRO) telephone number (844-430-9504) in the written notice provided to the patient prior to discharge. This failure could have prevented the patient from exercising their right to appeal the discharge decision. Review of the discharged patient roster provided to the surveyor by the Administrator/DON on 10/20/21 revealed Patient 1 was discharged on 7/22/2021 with the reason for discharge listed as "Goals Met." Review of the clinical record for Patient 1 revealed signed document “Notice of Medicare Non-Coverage” signed by the patient and dated the same day as discharge 07/22/2021. The telephone number listed for the QIO was XXX-XXX-4227 which was not the correct number for the QIO. Review of the clinical record for Patient 1 failed to find any evidence that the patient received the "Notice of Medicare Provider Non-coverage" with the correct contact information at least two days before discharge. An interview was conducted on 10/26/2021 at approximately 1:25 PM with the Administrator/DON. The surveyor reviewed the findings of the record review for Patient #1 including the lack of 2-day notice and the incorrect contact information for the QIO. The Administrator/DON stated this was previously cited and they were now providing the form and would correct the phone number on the form. Review of the policy titled: “Patient/Client Transfer, Discharge and Agency Dissolution PE.5” dated 011318 read in part: “Purpose… To Provide patient/clients in original Medicare access to an expedited determination process when their Medicare covered Home Health Agency services are ending… The Agency will provide notice to eligible patients/clients of their right to expedited determinations using the notice of Medicare Non-Coverage (… Medicare form) when their period of covered care ends… The Agency will provide the Advance Beneficiary Notice (ABN) according to the procedures in the Billing Process/Advance Beneficiary Notice/False Claims policy…” Review of the policy titled: “Billing Process/Advance Beneficiary Notice/False Claims RI.10” dated 011318 read in part: “ The Agency will prepare and deliver to the Medicare patient/client or their authorized representative, an Advance Beneficiary Notice (ABN) …when there is a reduction or termination of home health services…Patient/client Goals Met- All care ending with the patient/client goals met or physician orders completed (NOMNC must be given)… ABN Delivery: …The beneficiary or their representative must sign the notice to indicate that he or she has received the notice and understands its contents…The beneficiary (or representative) must write the date he or she signed the ABN…. The NOMNC informs the patient/client or their authorized representative of the right to an expedited determination by a Quality Improvement Organization (QIO) if they feel that termination of home health services is not appropriate…

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct any Performance Improvement Projects for 3 (2018, 2019, and 2020) of three years of the survey review period. This failure placed the agency's patients at risk of receiving inadequate care and services that could lead to negative health outcomes. The surveyor requested all agency QAPI documents/reports/manuals on 10/20/2021. A white three ring binder labeled "QAPI" was provided by the Administrator. The surveyor reviewed the records contained in the QAPI binder provided on 10/26/2021. A review of the entire binder revealed no documentation of Performance Improvement Projects for 2018, 2019, and 2020. Review of the agency policy and procedures manual revealed a policy titled: “Quality Assessment Performance Program QAPI.1” which read in part: “Performance improvement projects 1. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency’s services and operations. 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and measurable progress achieved on these projects…” An interview was conducted on 10/26/2021 at 12:45 PM with the Administrator. The surveyor shared the findings of the review of the QAPI policies, plan, and documents provided by the agency. The surveyor stated there was no evidence of Performance Improvement Projects found for 2018, 2019, and 2020. Employee A replied: “What happened is we don’t have a lot of patients.” The Administrator also stated that they had not been able to review the Medicare reports for clinical outcomes “as we cannot log in.” The agency did not dispute the survey findings and did not provide any additional documentation to explain or correct the findings.