Every finding on record at Angel's Hope Home Health, Inc.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. An unannounced on-site Recertification survey at the above-named Home Health Agency (HHA) from 02/05/25 to 02/07/25 resulted in a finding of no citations respective to the Emergency Preparedness Program Condition of Participation under 42 CRF 484.102.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Department of Health and Human Services. An unannounced on-site Recertification Survey conducted at the above-named Home Health Agency (HHA) facility from 02/05/25 to 02/07/25 resulted in a finding of non-compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C and the following standard-level deficiencies listed below.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the Home Health Agency (HHA) failed to maintain an up-to-date medication profile for one of four (Patient (P)) 3 reviewed for home visits. The agency's failure to maintain a current medication list had the potential to affect all 188 patients receiving services by the HHA. Findings include: Review of the agency’s undated policy titled, "Medication Reconciliation," revealed, "…Procedure 2. The medication list/profile will be updated with each new or changed medication…." Review of P3's electronic medical record (EMR) under the "Admissions" tab revealed an admission date of 01/05/25 and diagnoses that included diabetes, heart disease and hypertension. Review of the "Physician Orders" dated 01/05/25 located in the EMR under the "Orders" tab revealed the physician ordered Claritin (used to treat allergy symptoms) 10 milligrams (mg) oral daily, Spironolactone (a diuretic) 25mg oral daily and Potassium Chloride Extended Release (a supplement) 20 milliequivalents oral daily. A home visit for P3 was conducted on 02/05/25 at 11:30 AM with the Executive Director/Director of Nursing. Interview with P3 during the visit confirmed he/she was not currently taking Claritin, Spironolactone or Potassium Chloride Extended Release. During an interview on 02/05/25 at 2:30 PM, the Executive Director/Director of Nursing acknowledged P3’s medication list contained medications that he/she was not currently taking and confirmed the agency failed to notify the physician that P3 stopped taking the medications.

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 policy review, Quality Assurance Performance Improvement (QAPI) document review, and interview, the Home Health Agency (HHA) failed to develop and implement a QAPI program that included quality indicators for high risk and high volume indicators. The HHA failure to include high risk and volume quality indicators had the potential to affect the188 patients receiving services from the HHA. Findings include: Review of the Agency’s undated policy titled, "Quality Assessment and Performance Improvement (QAPI) Plan and Program," revealed, "…directed staff to collect data including care that is high-risk, high volume and problem prone areas …collection of data regarding the point of care laboratory testing as allowed by Certified Laboratory Improvement Assessments (CLIA) waiver.…" Review of the QAPI data collected by the agency did not include indicators for the high-risk care the agency provided that included frequent intravenous medication administration, the high volume of wound care and problem prone areas including patient falls. During an interview on 02/05/25 at 3:30 PM, the Executive Director/Director of Nursing acknowledged the agency had a change in staffing and were in the process of reimplementing their QAPI program. The Executive Director/Director of Nursing confirmed the agency identified the need for data collection in multiple areas of patient care. The Executive Director/Director of Nursing stated the agency had not identified the lack of a current CLIA certificate and had not educated the staff on the new QAPI process.

Laboratory services/CLIA waivers CFR(s): 484.100(c)(1) Laboratory services. If the HHA engages in laboratory testing outside of the context of assisting an individual in self-administering a test with an appliance that has been cleared for that purpose by the Food and Drug Administration, the testing must be in compliance with all applicable requirements of part 493 of this chapter. The HHA may not substitute its equipment for a patient's equipment when assisting with self-administered tests. This STANDARD is not met as evidenced by: Based on record review, observation, document review, and interview, the facility failed to maintain a current Clinical Laboratory Improvement Amendments (CLIA) waiver for laboratory testing performed by the Home Health Agency (HHA). The agency’s failure to maintain a current CLIA waiver certificate places patients who require glucose monitoring at risk for inaccurate or inadequate monitoring. Findings include: Review of the CLIA waiver certificate, displayed by the HHA in the entry to the office, revealed the certificate expired on 02/06/25. Review of Patient (P) 9's Electronic Medical Record (EMR) located under the "Admissions" tab, revealed P9 was admitted to home health services on 01/05/25 with diagnoses that included Type 2 Diabetes Mellitus. Review of the "Physician Orders" revealed an order to conduct finger stick blood glucose monitoring. During a home visit on 02/07/25 at 9:00 AM, Licensed Practical Nurse (LPN) 2, performed a finger stick blood glucose test on P9 using the agency’s blood glucose meter. During an interview on 02/07/25 at 2:00 PM, the Director of Nursing (DON) confirmed the CLIA certificate expired on 02/06/25 and the agency failed to reapply for a CLIA certificate renewal. The DON stated glucose monitoring is the only waived test the agency conducts.

This Statement of Deficiencies was generated as a result of an Emergency Preparedness survey conducted at your facility on 3-29-2022 through 3-31-2022, in accordance with 42 Code of Federal Regulations (CFR) and the State Operations Manual (SOM), Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigations, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following deficiencies were identified:

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: Based on interview and document review the agency's Emergency Preparedness (EP) Plan failed to include a communication plan which included the names and contact information of staff members, names of contracted services, contact information for patients' physicians, volunteers and of similar provider types . Findings include: The agency's Emergency Preparedness Plan revealed their communication plan would contain the names and contact information of staff members, contracted services, patients physicians and volunteers . On 3-30-2022 in the afternoon, the Director of Nursing (DON) verified the agency's EP communication plan lacked the required information of names and contact information of staff members, contracted services, and for patients' physicians and of similar provider types.

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: Based on interview and document review, the agency's Emergency Preparedness (EP) Plan failed to establish an agreement with the local radio station to provide emergency communication with their patients and staff members or obtain the 2-way radios as documented in the EP communication plan Findings include: The agency's Emergency Preparedness Plan revealed if phones were not available, the Emergency Coordinator would contact two (2) prearranged radio stations with an announcement for staff and patients. On 3-30-2022 in the afternoon, the Director of Nursing (DON) verbalized the agency had not contacted/ or had an agreement with the local radio stations documented in the EP communication plan regarding sending out announcements for their staff members and patients. On 3-30-2022 at 2:53 PM, a contracted employee revealed the agency had a 2-way radio at the office to communicate with staff in the field. The employee had not been provided a 2-way radio. On 3-31-2022 in the afternoon, the DON revealed if the telephone lines were down the agency had a 2-way radio to communicate with staff members in the field and verified this was documented in the agency's communication plan. The DON was not able to locate the 2-way radios as an alternate form of communication and confirmed the staff had not been provided a 2-way radio.

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: Based on document review and interview, the agency failed to provide training on Emergency Preparedness (EP) policies and procedures to all new and existing staff members and individuals providing services under arrangement and failed to ensure staff could demonstrate knowledge of emergency procedures. Findings include: The agency's EP policy indicated initial training in emergency preparedness would be provided to all new and existing staff members, individuals providing services under arrangement, and volunteers consistent with their expected roles. The Emergency Preparedness (EP) training was to be completed at least annually, documented in the training file in the EP Manual and demonstrate staff knowledge of emergency procedures The in-service training binders for 2021 and 2022 lacked documented evidence all staff members had received annual EP training in accordance with the agency's policy. The DON verified there was no documentation all staff members had received annual EP training in 2021 and 2022. An in-service record dated 3-12-2021 for Emergency Management training contained the signatures of 15 staff members had who attended the training. There was no documented evidence all 37 staff members had received EP training. There was no documentation the agency had tested the knowledge of the 15 staff members after the training. On 3-30-2022 in the afternoon, a Registered Nurse indicated the agency had not completed EP training for 2022. On 3-30-2022 in the afternoon, the Director of Nursing (DON) stated the facility did not test the staff members knowledge after in-service testing. On 3-30-2022 in the afternoon, the DON provided documentation which indicated the agency had hired 6 new employees from April to December of 2021 and in 2022 the agency had hired 2 new employees. There was no documented evidence the newly hired staff members in 2021 and 2022 had received initial EP training. The DON verified there was no documentation to show EP training had been completed for the new employees. On 3-31-2022 at 11:46 AM, the DON was not able to locate the in-service binder for 2020 and was not able to provide documented evidence the staff had received EP training.

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), §485.625(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, 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 interview and document review, the agency failed failed to participate in drills, tabletop exercises, community or facility- based exercises on an annual basis as documented in the facility's Emergency Preparedness (EP) Plan. Findings include: The agency's Emergency Preparedness Plan (EP) documented the training exercise would be conducted at least annually. The agency would participate in a full-scale exercise that was community-based or when a community-based exercise was not accessible, an individual, agency-based. The 2021 in-service training binder documented active shooter training was completed on 1-8-2021. There was no documented evidence to show staff members had attended the training. On 3-30-2022 at 1:23 PM, the Director of Nursing (DON) verbalized the agency had completed a tabletop exercise for an active shooter and confirmed there was no documentation to show staff members had attended the training. The 2022 in-service training binder lacked documented evidence the agency had completed drills or tabletop exercises, or participate in community or facility- based exercises. There was no documented evidence the agency had activated their EP plan during the Covid-19 pandemic. This was confirmed by the DON. On 3-31-2022 at 11:46 the DON was not able to locate documentation the agency had completed drills, tabletop exercises, community or facility- based exercises in 2020.

This Statement of Deficiencies was generated as a result of the Medicare Recertification survey and Healthcare Worker (HCW) Vaccine Mandate conducted at your agency from March 29, 2022 through April 01, 2022 , in accordance with 42 CFR (Code of Federal Regulations) Part 484 - Home Health Services. Seven clinical records were reviewed. Three home visits were conducted. The investigation of regulatory compliance for COVID-19 Vaccination of Facility Staff included: - Review of Infection Control Surveillance plans. - Review of Vaccination policies including staff members vaccination status, exemptions, (medical and non-medical), temporary delays for vaccinations, additional precautions for unvaccinated staff, contingency plans for unvaccinated staff and additional precautions to prevent the spread of Covid -19. Review of the facility's Healthcare Worker Vaccination policies and facility documentation revealed the facility was at 100% compliance with Healthcare Worker vaccination requirements. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:

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 record review and interview, the agency failed to comply with CMS (Centers for Medicare/Medicaid) time sensitive requirements for electronically submitting data. Findings include: Prior to the survey, the state's OASIS (Outcome and Assessment Information Set) Education Coordinator provided a report, revealing the agency failed to electronically submit required data in five of the last eight quarters and maintain an error rate below 10%. According to the agency's last two quarters ending 12/31/2021 and 3/30/2022, the agency had failure rates of 29.37% and 35% respectively, regarding electronically submitting its OASIS data within 30 days. On 4/01/2022 in the late morning with the Clinical Manager present, a Registered Nurse indicated the agency had three registered nurses conducting the OASIS assessments and had a challenging time maintaining currency with data submission.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure a patient had the correct ordered catheter size inserted for 1 of 7 patients (Patient #4). Findings include: Patient #4 On 4/23/2021, the agency admitted Patient #4 with stage 2 pressure sore of right buttocks and encounter for fitting and adjustment of urinary device. On 12/07/2021, a urologist ordered a suprapubic catheter change every 4 weeks with a 20 f (french) 5 cc (cubic centimeter) catheter. The agency recertified Patient #4 from 2/17/2022 through 4/17/2022. On 2/17/2022, a physician ordered weekly skilled nursing visits. On 2/23/2022, a Licensed Practical Nurse documented a suprapubic catheter change. The genitourinary system assessment showed the patient had a 20 f 30 cc catheter. From 2/25/2022 to 3/07/2022, Patient #4 was in a hospital. On 3/11/2022, the same Licensed Practical Nurse documented the genitourinary system assessment which showed the patient had a 22 f 5 cc catheter. On 3/16/2022, the same Licensed Practical Nurse documented the genitourinary system assessment which showed the patient had a 22 f 5 cc catheter. On 4/01/2022, the Clinical Manager and a Registered Nurse verified the discrepancy.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency conducted a skilled nursing visit without a physician order for 1 of 7 patients (Patient #3). Findings include: Patient #3 On 2/23/2022, the agency admitted Patient #3 with cerebral infarction. On 2/23/2022, the plan of care showed a physician ordered weekly skilled nursing visits starting 3/06/2022. On 2/28/2022, the electronic clinical record showed a Licensed Practical Nurse conducted and documented a skilled nursing visit. On 3/31/2022 at 3:00 PM, the agency scheduled another skilled nursing visit with the inspector and the same Licensed Practical Nurse. The clinical record lacked documented evidence of a physician order to conduct a second skilled nursing visit for the week. On 4/01/2022 in the late morning, the Clinical Manager and a Registered Nurse verified the clinical record lacked documented evidence of a physician order to conduct a second skilled nursing visit for the week.

Integrate all orders CFR(s): 484.60(d)(2) Integrate orders from all physicians or allowed practitioners involved in the plan of care to assure the coordination of all services and interventions provided to the patient. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to integrate a patient's urologist's catheter change frequency order into the plan of care for 1 of 7 patients (Patient #4). Findings include: Patient #4 On 4/23/2021, the agency admitted Patient #4 with stage 2 pressure sore of right buttocks and encounter for fitting and adjustment of urinary device. On 12/07/2021, a urologist ordered a suprapubic catheter change every 4 weeks with a 20 f (french) 5 cc (cubic centimeter) catheter. The agency recertified Patient #4 from 2/17/2022 through 4/17/2022. On 2/17/2022, a physician ordered weekly skilled nursing visits. On 2/23/2022, a Licensed Practical Nurse documented a suprapubic catheter change. The genitourinary system assessment showed the patient had a 20 f 30 cc catheter. From 2/25/2022 to 3/07/2022, Patient #4 was in a hospital. On 3/11/2022, the same Licensed Practical Nurse documented the genitourinary system assessment which showed the patient had a 22 f 5 cc catheter. On 3/16/2022, the same Licensed Practical Nurse documented the genitourinary system assessment which showed the patient had a 22 f 5 cc catheter. The plan of care lacked documented evidence the agency accepted orders from the patient's urologist and failed to document any catheter change frequency on the plan of care. On 4/01/2022, the Clinical Manager and a Registered Nurse verified the discrepancy.

Clinical Manager CFR(s): 484.115(c) Standard: Clinical manager. A person who is a licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker, or a registered nurse. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure inspectors were screened regarding Covid-19 upon entry to the agency's office. Findings include: On 3/29/2022 and 3/30/2022, the agency seated two inspectors at a table within the agency's office in order to conduct an inspection. Near the table area, a posted leaflet instructed the agency to screen individuals in the office for Covid-19. Neither inspector was screened, and inspectors observed several employees who were not wearing masks as required. Temperatures were not taken until the third day of the survey, after the inspectors inquired about the issue. Prior to the survey in a written report, the OASIS Education Coordinator indicated the agency failed to submit a completed Focused Infection Control Survey in April 2020, despite three documented requests to the agency to do so. On 4/01/2022 in the late morning, the Clinical Manager and a Registered Nurse indicated the agency was supposed to screen individuals for Covid-19.