Every finding on record at Apollo Medical Holdings, LLC

Saint Louis, Missouri · CCN 267580

26 findings across 2 surveys, in the inspector's own words.

The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.

Survey of January 25, 2024

13 findings

E0000

The Emergency Preparedness regulations were reviewed as part of the Medicare recertification survey completed on 01/25/2024. During the survey it was determined the home health provider is in compliance with the requirements of 42 CFR 484.102 Condition of Participation: Emergency Preparedness for Home Health Providers.

G0000

A partial extended survey for Medicare recertification for the home health provider was completed on 01/25/2024. The provider had 176 current patients.

G0444

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on the home health provider's admission packet review and interview, the provider failed to ensure that the correct hours of operation of the state toll free home health hotline (7:00 AM to 8:00 PM, seven days a week) were provided to the patient in one of one admission packet reviewed. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the patient admission packet showed that the patient had the right to "be advised of the state toll free home health telephone hotline, its contact information, its hours of operation, and its purpose is to receive complaints or questions about local home health agencies (HHA). 1-800-392-0210; 7:00 AM - 12 midnight 7 days a week." During an interview on 01/24/2024 at 3:30 PM, the home health administrator stated that he/she was not aware of the hour change from 7:00 AM - 12 midnight to 7:00 AM - 8:00 PM. He/she also stated that he/she would expect the correct hotline hours to be contained in the admission packets and provided to patients.

G0536

G0574

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that the individualized plan of care (POC) contained all types of services, supplies, and equipment required for patient care in two of five full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider's undated policy titled, "Plan of Care," showed, in part, the following: -A POC is the written orders for the individualized care for a patient; and -POC will be address at all Outcome and Assessment Information Set (OASIS) timepoints for accurate goals and interventions for the individual patient. RECORD/PATIENT #4: Review of the document titled, "Occupational Therapy (OT) Start of Care (SOC) OASIS," showed the following: -Patient has "fallen 12 times over the past few months"; *The POC failed to contain interventions for fall risk; -Patient incontinent of bowel and bladder; *The POC failed to contain interventions for incontinence; -The patient used durable medical equipment (DME) such as transfer devices; and *The POC failed to contain interventions for DME. During an interview on 01/25/2024 at 9:00 AM, the home health administrator stated that he/she would expect individualized interventions to be included on the POC. Findings included: Review of the provider’s undated policy titled, “Plan of Care,” showed in part: - A POC is the written orders for the individualized care for a patient; - All POCs will be updated to reflect any new or changed physician’s orders to assure correct treatment according to the POC; - Coordination of care between all disciplines and ordering physician will be documented; and - POC will be address at all Outcome and Assessment Information Set (OASIS) timepoints for accurate goals and interventions for the individual patient. Review of the initial assessment dated 11/22/2023, showed in part: -The patient had been hospitalized for two months after cardiothoracic bypass surgery. After extubation (removal of a tube that had been placed in the lungs to help with breathing) the patient was coughing while eating. The patient had lost 20 pounds while hospitalized. The patient has a good appetite and is trying to eat a soft high protein diet. The nurse encouraged the patient to drink ensure and cough after small bites; - Referrals were made to ST (speech therapy) and OT (occupational therapy); and -The nurse changed the abdominal dressing where the LVAD (heart assistive device) tubing was. The nurse noticed scant sanguineous (bloody) drainage. The patient stated that the drainage had decreased. Review of the POC dated 11/22/2023, showed the patient would benefit from skilled therapy. The POC failed to include orders for ST, OT, or abdominal dressing changes. During an interview on 01/24/2024, beginning at 11:30 AM, the administrator stated that the nurse should have called the physician to get orders. They should have notified the clinical manager and discussed therapy in case conference. The patient was probably not stable enough for physical therapy at that time, but there should be more information regarding therapy documented in their notes. There should have been orders for the abdominal dressing.

G0580

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 home health provider failed to ensure physician orders were obtained for treatment in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: RECORD/PATIENT #2: Review of the initial assessment dated 11/22/2023, showed the nurse changed the abdominal dressing where the LVAD (heart assistive device) tubing was. The nurse noticed scant sanguineous (bloody) drainage. The patient stated that the drainage had decreased. Review of the skilled nurse (SN) visits showed on 12/12/2023, 12/19/2023, 12/20/2023, and12/26/2023 an intervention to assess surgical incision for healing and signs and symptoms of infection. Incision site-LVAD cord insertion site. Incision care-Cleanse with wound cleanser and cover with gauze. Review of the clinical record failed to show a physician order for this treatment. During an interview on 01/24/2023, beginning at 11:30 AM, the home health administrator stated that there should have been an order for the abdominal dressing.

G0590

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview the home health provider failed to ensure nursing staff notified the physician of one patient’s change in condition (Record/Patient #2) and failed to notify the physician of missed visits in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed: -An occupational therapy (OT) visit scheduled for 01/12/2024 that was missed; -Two physical therapy (PT) visits scheduled for the week of 01/15/2024 that were missed; and -Two OT visits scheduled for the week on 01/15/2024 that were missed. The provider could not provide documentation to show that the physician was notified of the missed clinician visits. During an interview of 01/25/2024 at 9:00 AM, the home health administrator stated that he/she would expect all missed visits to be reported to the physician or rescheduled. Findings included: RECORD/PATIENT #2: Review of the initial assessment dated 11/22/2023, showed the patient was admitted after a two month hospital stay. The patient had cardiothoracic bypass surgery. The patient had an LVAD (heart assistive device) placed while hospitalized. He/she also had a central line in the right upper chest and dobutamine (a medication that helps the heart pump blood) infusing. Review of the plan of care (POC) dated 11/22/2023, showed diagnoses that included atherosclerotic heart disease (damage or disease to the heart’s major blood vessels), end stage heart failure and presence of a heart assist device (a pump that helps the heart to pump blood to the body). Review of the skilled nurse (SN) visits showed: - On 12/27/2023, breath sounds were clear with no cough; - On 01/03/2024, the patient stated that he/she had been dealing with some health issues lately, including a nosebleed, diarrhea, and phlegm. Under the gastrointestinal assessment the patient had diarrhea and started Immodium (anti-diarrheal) one day ago. The LVAD (heart assistive device) nurse was aware. The patient had a productive cough with a small amount of clear and yellow thick sputum (phlegm). The respiratory findings showed no problems noted or verbalized. The nurse failed to document breath sounds, or that he/she notified the physician of the nosebleed, diarrhea, and productive cough with clear, yellow sputum; and - On 01/06/2024, the patient had a productive cough with a small amount of clear and yellow thick sputum. The respiratory findings showed no problems noted or verbalized. The nurse failed to document breath sounds, vital signs, or that he/she notified the physician of the patient’s productive cough with thick clear, yellow sputum. Review of the transfer OASIS (outcome assessment and information set) dated 01/08/2024, showed the patient was transferred to the hospital. Diagnoses included pneumonia, protein calorie malnutrition, left ventricular assist device present, and anemia. During an interview on 01/24/2024, beginning at 11:30 AM, the administrator stated that he/she would have expected the nurse to notify the physician of the patient’s nosebleed and productive cough. During an interview on 01/25/2024, beginning at 10:00 AM, the administrator stated that they did not have a specific policy regarding physician notification. They followed the conditions of participation for physician notification.

G0614

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on policy review, observation, and interview the home health provider failed to ensure the patient received a visit schedule that included what disciplines were seeing the patient and the frequency of visits in one of three home visit observations (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Plan of Care,” showed in part that written instructions will be provided to the patient/caregiver/patient representative. The written instructions will include the visit frequency for each discipline. RECORD/PATIENT #2: Observation and interview on 01/23/2024, beginning at 2:35 PM, during the patient’s home visit, showed the patient’s admission folder contained a blank form/calendar for visit schedules. The physical therapist stated that their schedule changed all the time, but they usually put the visit frequency on the form. During an interview on 01/24/2024, beginning at 11:30 AM, the home health administrator stated that staff should use the calendar for their visit schedules.

G0616

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on policy review, observation, and interview the home health provider failed to ensure the patient received a medication list in one of three home visit observations (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Plan of Care,” showed in part that written instructions will be provided to the patient/caregiver/patient representative. The written instructions will include a medication list. RECORD/PATIENT #2: Observation and interview on 01/23/2024, beginning at 2:35 PM, showed the patient’s admission folder failed to contain a medication list for the patient. The patient stated that he/she did not think he/she had one. The only medication list he/she had was from the last time he/she was in the hospital. During an interview on 01/24/2024, beginning at 11:30 AM, the home health administrator stated that staff should use whatever medication list was in the home. Staff could use the discharge medication list and update that as needed.

G0682

G0706

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure nursing staff documented complete physical assessments to include vital signs and lung sounds for one patient (Record/Patient #2) and failed to document complete wound and pain assessments for one patient (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Wound Care,” showed in part: - A wound assessment to be completed at each visit to include tissue type, wound bed, wound exudate (drainage), periwound (surrounding skin) condition, pain level with dressing change, and size (length, width, and depth); and - Measurements are to be completed with the first visit of each week. During an interview on 01/25/2024, at 10:00 AM, the home health administrator stated that they did not have a specific policy for pain assessments. They were working on one, but it had not yet been approved. RECORD/PATIENT #2: Review of the record showed the patient was admitted on 11/22/2023, after a two month hospital stay. The patient had cardiothoracic bypass surgery. The patient had an LVAD (a heart assistive device that helps the heart to pump blood to the body). Review of the plan of care (POC) dated 11/22/2023, showed diagnoses that included atherosclerotic heart disease (damage or disease to the heart’s major blood vessels) and hypertensive heart disease with heart failure (a chronic disease that makes it harder for your heart to pump blood which can lead to heart failure). Review of the skilled nurse (SN) visits showed: - On 12/27/2023, breath sounds were clear with no cough; - On 01/03/2024, productive cough with a small amount of clear and yellow thick sputum (phlegm). The respiratory findings showed no problems noted or verbalized. The nurse failed to document breath sounds; and - On 01/06/2024, productive cough with a small amount of clear and yellow thick sputum. The respiratory findings showed no problems noted or verbalized. The nurse failed to document breath sounds or vital signs. During an interview on 01/24/2024, at 12:35 PM, the home health administrator stated that vital signs and breath sounds should be documented. RECORD/PATIENT #5: Review of the record showed the patient was admitted on 11/16/2023, after hospitalization for a colostomy takedown (a colostomy is a surgical procedure to create a passage from the large intestine to the outside of the body, a colostomy takedown is the reversal of the colostomy to reattach the colon to the rectum). Review of the POC dated 11/16/2023, showed an order for wound vac (vacuum assisted closure of a wound) dressing change two times a week, assess for signs and symptoms of wound infection, and assess for pain including pain level, frequency, location, quality, precipitating factors, and side effects. Review of the SN visits showed: - On 11/16/2023, the patient had daily, intermittent pain, relief measures included non-narcotic over the counter pain relievers, occasionally affected sleep, and day to day activities. The pain assessment failed to include the location, quality, precipitating factors, and effectiveness of pain relief measures. The nurse changed the wound vac dressing but failed to document an assessment/measurements of the wounds; - On 11/21/2023, the nurse failed to document measurements of the wounds; - On 11/24/2023, the nurse documented the anterior (front) medial abdomen midline surgical incision wound bed was clean. The nurse failed to document the tissue color of the wound bed, or whether drainage or odor was present. The nurse also failed to document measurements of the wounds. The patient had constant pain. Pain relief measures included non-narcotic over the counter pain relievers. The nurse failed to document the pain level, location, quality, precipitating factors, and effectiveness of pain relief measures; - On 11/28/2023, the patient had a physician appointment; - On 11/30/2023, the patient saw the surgeon and he/she applied steri strips to the anterior medial abdominal incision. The patient had moderate pain at a level of five (pain is rated on a scale of 0 to 10 with zero meaning no pain and 10 meaning the worst pain) daily intermittent pain that was aching and interfered with activity and movement. The patient used narcotic and over the counter pain relievers and was comfortable with his/her current treatment. The nurse failed to document the location of pain; - On 12/04/2023, the nurse failed to document a pain assessment; - On 12/07/2023, the patient saw his/her primary care physician and surgeon that day. The patient had increased abdominal pain the last few days. The pain assessment showed the patient had daily, intermittent, acute, aching pain at a level of two. The patient used narcotic and over the counter pain relievers. The patient was comfortable with his/her current treatment. The nurse failed to document the location of the pain. The family member said the wound vac was being discontinued. Steri strips (adhesive strips that protect and hold a wound together) were placed on the midline abdominal incision and the physician placed a wet to dry dressing on the old stoma site. A CT (computerized tomography, shows detailed images inside the body) scan was ordered for the following day. No abdominal redness, warmth, or swelling noted. The nurse would follow up with the physician for current wound care orders. The RNCM (registered nurse case manager) and home health office was notified; and - On 12/09/2023, the patient’s family notified the provider that the patient had passed away. During an interview on 01/24/2024, beginning at 2:55 PM, the home health administrator stated that the nurse should assess the wound bed, drainage, odor and measure the wounds weekly. He/she would expect a pain assessment to include the rating, location, and what made it better or worse.

G0710

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review, observation, and interview the home health provider failed to ensure staff followed the physician ordered plan of care (POC) in two of five full records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #3: Review of the verbal orders dated 01/11/2024 showed the following occupational therapy (OT) orders: -Activities of daily living (ADL) training; -Aerobic capacity training; -Assess ADL skills; -Assess aerobic capacity; -Assess transfer ability; -Establish/upgrade home exercise program/walking program for aerobic capacity/activity tolerance; and -Instruct patient/caregiver on safety awareness, energy conservation, compensation techniques for safe performance of ADLs, proper use of adaptive/assistive devices. Observation on 01/23/2024 at 5:00 PM, during the patient's home visit, showed OT-A failed to perform the ordered interventions for the patient's care. During an interview on 01/25/2024 at 9:00 AM, the home health administrator stated that he/she would expect care to be performed as ordered by the physician. Findings included: RECORD/PATIENT #2: Review of the record showed the patient was admitted on 11/22/2023, after a two month hospital stay. The patient had cardiothoracic bypass surgery. The patient had an LVAD (heart assistive device) placed while hospitalized. He/she also had a central line in the right upper chest and dobutamine (a medication that helps the heart pump blood) infusing. Review of the POC dated 11/22/2023, showed an order for central line/PICC (peripherally inserted central catheter) line care weekly. The nurse was to measure the upper arm circumference and distance from the IV (intravenous) hub to the insertion site at the start of care, discharge, and as needed for IV complications. Review of the initial assessment dated 11/22/2023, showed the nurse failed to document measurements of the upper arm circumference and length of the central line catheter. Review of the nursing visit dated 11/28/2023, showed the nurse failed to document that he/she changed the central line/PICC line dressing. During an interview on 01/24/2024, beginning at 11:30 AM, the administrator stated that they should have the catheter measurements on the referral, but sometimes it was difficult to obtain those measurements. Staff should document these measurements and document they changed the central/ PICC line dressing.

G1024

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed ensure the timeliness of documentation in five of five full records reviewed (Records/Patients #1, #2, #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #2: Review of the record showed: - An SN visit dated 11/28/23, and signed as completed on 12/02/2023 (four days after the visit); - An SN visit dated 12/26/2023, and signed as completed on 01/01/2024 (six days after the visit); and - An SN visit dated 12/27/2023, and signed as completed on 01/01/2024 (five days after the visit. RECORD/PATIENT #5: - An SN visit dated 11/16/2023 and signed as completed on 11/20/2023 (four days after the visit); and - An SN visit dated 11/21/2023 and signed as completed on 12/03/2023 (12 days after the visit). Findings included: Review of the provider's undated policy titled," Initial Assessment," showed a complete comprehensive assessment will be completed in a timely manner, consistent with the patient's immediate needs, but no longer than 5 calendar days after the start of care (SOC). Review of the provider's undated policy titled," Clinical Documentation Policy," showed all documentation, regardless of visit type, must be submitted within 48 hours of a performed visit. RECORD/PATIENT #1: Review of the clinical record showed the following: -A skilled nurse (SN) visit dated 01/16/2024 documented 01/21/2024, 5 days after visit; -A physical therapy (PT) evaluation dated 01/09/2024 documented 01/17/2024, 8 days after visit; -An occupational therapy (OT) evaluation dated 12/26/2023 documented 01/02/2024, 7 days after visit; and -An OT visit dated 01/08/2024 documented 01/15/2024, 7 days after visit. RECORD/PATIENT #3: Review of the clinical record showed the following: -A SN initial assessment dated 12/20/2023 documented 12/28/2023, 8 days after visit; -A SN visit dated 12/27/2023 documented 12/31/2023, 4 days after visit; -An OT visit dated 01/03/2024 documented 01/15/2024, 12 days after visit; and -An OT missed visit dated 01/18/2024 documented 01/22/2024, 4 days after missed visit. RECORD/PATIENT #4: Review of the clinical record showed the following: -A certified occupational therapy assistant (COTA) visit dated 01/11/2024 documented 01/14/2024, 3 days after visit; and -A COTA visit dated 01/18/2024 documented 01/22/2024, 4 days after visit. During an interview on 01/25/2024 at 9:00 AM, the home health administrator stated that he/she would expect documentation to be completed according to policy and within a timely manner.

Survey of May 6, 2021

13 findings

E0037

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 policy review, employee file review, and interview, the agency failed to ensure staff were provided emergency preparedness training annually for three (Employee #1, #2, and #3) of three employee files reviewed. This deficient practice has the potential to affect the emergency preparedness practices for all agency staff. Findings included: Review of the agency's policy titled "Emergency Preparedness" revised April, 2020 showed: - Did not address the annual training of employees. EMPLOYEE #1 (E1): Review of the employee file showed: - Licensed as a registered nurse (RN); - Date of hire: 01/25/2021; - No record of emergency preparedness training. EMPLOYEE #2 (E2): Review of the employee file showed: - Licensed as a physical therapy assistant (PTA); - Date of hire: 10/15/2020; - No record of emergency preparedness training. EMPLOYEE #3 (E3): Review of the employee file showed: - Licensed as a master social worker (MSW); - Date of hire: 03/10/2020; - No record of emergency preparedness training. During an interview on 05/04/2021 at 3:30 PM, the administrator stated that the agency did emergency preparedness training and all staff attended the training but the training was not recorded in the employee files.

G0000

A partial extended survey for Medicare certification for Apollo Medical Home Health was completed on 05/06/2021. The agency had 197 current patients. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and one deficiency was identified related to the Focused Infection Control Survey. The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 05/06/2021. One standard level deficiency was identified.

G0440

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to meet the requirements of the updated Federal home health regulations effective 11/29/2019 to include the patient has the right to be advised orally and in writing of the extent to which payment for services may be expected from Medicare, Medicaid, or any other Federally funded or Federal aid known to the agency; the charges for services that may not be covered by Medicare, Medicaid or any other Federally funded or Federal aid program known to the agency; the charges the individual may have to pay before care is initiated; and be advised of any changes in the information when they occur, as soon as possible, in advance of the next home health visit. This affected three (Record/Patient #1, #2, and #3) of three home visit information packets reviewed. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all patients served by the agency. Findings included: The agency clinical manager provided an admission packet for review on 05/03/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no written information regarding the patient's right to be advised of financial liability changes as soon as possible, in advance of the next home health visit. During the home visit observations of Patients #1, #2 and #3 the written patient rights information was reviewed in the patients' home folder. All home visits showed the same missing information as the above admission packet review. On 05/05/2021 at 11:47 AM, the findings were reviewed with the agency administrator. No additional information was provided.

G0446

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to meet the requirements of the updated Federal home health regulations effective 11/29/2019 to include the patient has the right to be advised of the names, addresses, and telephone numbers of the Quality Improvement Organization that serves the area where the patient resides. This affected three (Record/Patient #1, #2, and #3) of three home visit information packets reviewed. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all patients served by the agency. Findings included: The agency clinical nurse manager provided an admission packet for review on 05/03/2021. The agency notice of patient rights and other information given to a patient during the initial visit showed the written information for the patient and representative (if any) should be advised of the name, address, and telephone number of the following Federally funded and State funded entities that serve the area where the patient resides to include the Quality Improvement Organization (QIO). The agency had St. Louis Quality Assurance Association (STLQAA) listed (current QIO is Livanta). During the home visit observations of Patients #1, #2 and #3 the written patient rights information was reviewed in the patients' home folder. All home visits showed the same missing information as the above admission packet review. On 05/05/2021 at 11:47 AM, the findings were reviewed with the agency administrator. No additional information was provided.

G0536

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to maintain a complete/accurate medication profile in two (Record/Patient #1 and #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Medication Reviews/Reconciliations," updated and reviewed 02/2021, showed in part: - Medication reconciliation is to consist of a reconciliation between discharge/patient medication lists and medications (prescription and over the counter) found in the patient's home and electronic medical record (EMR) medication list. This is the direct hands on medication review. A medication review is asking the patient about changes in medications at every visit; - Policy: To assure all patients are correctly and safely taking all medications and to assure that the patient is taking the correct medication, correct dose, correct frequency and at the correct time. To educate the patient about all new or changed medication. To inform ordering physician with an accurate medication list (when requested) and to inform physicians of any adverse reactions a patient may be experiencing as well as all severe/major interactions, as well as fax a list of medications with severe interactions; - Purpose: Each patient admitted to the agency will have present in his/her admission folder a complete, concise, and updated medication profile. The comprehensive assessment will include a review of all medications the patient is currently using in order to identify potential adverse effects and drug reactions including ineffective drug therapy, significant side effects, significant drug interactions, duplicated drug therapy and non-compliance with drug therapy and communicate this with the patient and ordering physician; -The comparison addresses duplications, omissions, contraindications and interactions and the need to continue current medications; and -The types of information that clinicians use to reconcile medications include medication name, dose, route, frequency and purpose. RECORD/PATIENT #1: Review of the plan of care (POC) dated 04/22/2021 through 06/20/2021 showed: - The patient started care on 04/22/2021; and - Diagnoses included malignant neoplasm of pancreas (pancreatic cancer), type 2 diabetes (chronic condition that affects the way the body processes blood sugar), long term use of insulin, eosinophilic gastritis (chronic allergic/immune condition of the esophagus) and hypertension. During a home visit observation on 05/04/2021 beginning at 10:30 AM, review of the patient's medications in the home showed the following medications were not listed on the patient's medication profile provided by the agency: - Amlodipine Besylate (treats high blood pressure and chest pain) 2.5 milligram (mg) one daily at hour of sleep, the prescription was filled 02/23/2021; - Basaglar KwikPen (treats diabetes) 7 units under the skin every night, the prescription was filled 04/02/2021; - Diphenoxylate-Atropine (treats severe diarrhea) 2.5/0.025 mg, one tablet three times a day as needed for diarrhea; - Famotidine (antacid) one tablet twice a day and the medication was filled on 01/09/2021; and - Sprionolactone (treats high blood pressure) 25 mg, one tablet every day and the prescription was filled on 04/22/2021. During interview on 05/03/2021 at 10:45 AM, the patient said he/she took Lomotil. He/she used to take bee pollen and had taken it for a long time. The caregiver said the patient has a lot of vitamins and bee pollen and wants to take them and this has not been addressed and must have been an oversight. Review of a list of medications and supplements on an after care summary, undated, provided by the caregiver showed the following medications were not listed on the patient's medication profile provided by the agency: -Amlodipine Besylate 2.5 mg one time at bedtime, as of 03/20/2021; - "B5, B6 100 mg"; - Calcium citrate and D3 Calcium 500 mg and D3 400 international units (IU); - D3 2000 units; - Diphenoxylate (Lomotil) 2.5-0.025 one tablet three times a day for diarrhea; - Famotidine 20 mg two times a day; - Neovitin (vitamin and supplement) two tablets; - Omega 3 fish oil 1000 mg; - Potassium magnesium asparate 50 mg each; - Spironolactone (diuretic) 2.5 mg one tablet one time a day; and - Vitamin D2 50,000 IU, take 2 capsules orally once a day. During an interview on 05/05/2021 at 3:16 PM, the clinical manager said medications were missing from the patient's medication profile and the agency would update the plan of care. The nurse is to check the patient's medications once a week during a skilled nursing visit or during every skilled visit and ask the patient/family if there are changes in the medications. RECORD/PATIENT #2: Review of the skilled nurse (SN) start of care assessment dated 03/31/2021 showed: - Issues were identified during the drug regimen review; - New/changed medications identified was Meropenem (can treat infections) and the medication profile was updated; and -The nurse notified the physician. During a home visit observation and interview on 05/04/2021 beginning at 3:00 PM, the following medications were reviewed with the patient. The following discrepancies were found: - The discharge summary showed acetaminophen (used to treat mild to moderate pain) 325 mg two tablets every six hours as needed. The patient said he/she does take acetaminophen as needed for pain. The medication was not added to the plan of care and the medication profile provided by the agency; - The discharge summary showed Calcium carbonate (dietary supplement) 750 mg one tablet, three times a day. The patient said he/she takes calcium carbonate 750 mg one tablet three times a day with meals. The medication was not added to medication profile provided by the agency; - The discharge summary showed Cholecalciferol (Vitamin D3) 5,000 unit one tablet daily. This was not on the current medication profile provided by the agency; - The discharge summary showed Famotidine 40 mg one tablet daily, the patient's medication profile showed Famotidine 20 mg one tablet daily, and the patient said he/she takes Famotidine 40 mg daily; - The discharge summary showed gentamicin (antibiotic) 0.1% cream, apply to affected area daily. Apply to peritoneal dialysis site with daily dressing change. The patient said he/she applied gentamycin to his/her dialysis site every day. This was not on the patient's medication profile; - The discharge summary showed hydrocodone-acetaminophen (relief of moderate to severe pain) 5-325 mg one tablet by mouth every four hours as needed for moderate pain, maximum daily six tablets. The patient medication profile showed Hydrocodone-acetaminophen 5-325 mg every six hours; - Levothyroxine (treats hypothyroidism) 200 mcg (micrograms) one tablet daily in the morning. The patient said he/she has taken levothyroxine every morning for many years. This was not listed on the patient's medication profile; - The discharge summary showed Lumigan (helps lower pressure in the eye) 0.01% solution, one drop in both eyes daily at bedtime. The patient said he/she uses Lumigan eye drops in both eyes at bedtime. The eye drops were not listed on the medication profile; - The discharge summary showed montelukast (Singulair) (treats allergies)10 mg once daily at bedtime. The patient said he/she takes Singulair 10 mg at bedtime. This was not on the patient's medication profile provided by the agency; and - The discharge summary showed Vitamin B complex- Vitamin C folic acid 1 mg capsule, one capsule every third day. The patient said he/she takes "Vitamin B Complex" every three days. This was not listed on the patient's medication profile. During an interview on 05/05/2021 at 3:10 PM, the clinical manager stated that: - When reconciling medications the nurse needs to review the patient's medications in the home and the patient's discharge paperwork; - If there is a medication list in the home staff can update that list with current medications or the agency can provide a list; and - The medication issue on admission start of care assessment was Meropenum and there were no other medication issues documented.

G0574

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to ensure a complete/accurate plan of care (POC) that included all required information was completed in, but not limited to, two (Record/Patient #1 and #2) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency policy titled, "Plan of Care" revised/updated 04/2020, showed in part: - All plans of care (POC) will be updated and revised for all status changes the patient may have; - All POCs will be updated to reflect any new or changed physician's orders to assure correct treatment according to the POC; and - All verbal and written orders will be entered into the POC and interventions and goals updated to reflect the changes. RECORD/PATIENT #1: Review of a physician progress note included in the referral information provided by the agency, dated 04/22/2021 showed: - The patient was having diarrhea and had loose stools every two to three hours; - Swelling in the abdomen and genitalia and appeared larger over the past 24 hours and had a paracentesis (a procedure to drain excess fluid from the abdomen) during hospital stay and three liters of fluid was removed; - Significant swelling in the lower legs and used wraps and compression stockings; - Uterus had dropped and the nurses at rehabilitation had to push it back in on occasion; and - Recently diagnosed with diabetes mellitus type two (a disease characterized by high blood sugar, insulin resistance, and relative lack of insulin. A common symptom is wounds that do not heal) due to worsening pancreatic cancer. Checking blood sugars with each meal. The patient was started on insulin (helps your glucose for energy) with sliding scale (the progressive increase in pre-meal or nighttime insulin dose, based on pre-defined blood glucose ranges) and the regimen was somewhat overwhelming for the patient's family. Review of the plan of care dated 04/22/2021 failed to show the following interventions: - Assessment, management and education of diarrhea and loose stools; - Assessment, management and education of abdomen and genitalia swelling; - Assessment, management and education of swelling in the lower legs and interventions; - Physician orders for wraps and compression stockings for swelling in the lower legs; - Assessment, management and education of diabetes; and - Physician orders for how often blood sugars checked and monitored. During home visit observation and interview on 05/04/2021 at 10:30 AM, the patient had an abdominal tube and thigh high compression stockings (to improve blood flow in the veins of legs) to both legs. The case manager had changed the gauze dressing around the tube. The patient's caregiver stated "the abdominal tube was placed last Tuesday (04/27/2021), 5 liters of fluid was removed and a tube was inserted. They were instructed not to remove more than one liter of fluid at a time at home due to the possibility the patient's blood pressure could drop". The patient's caregiver said he/she would like to learn how to clean the tube and empty the drain. The case manager stated he/she found out about the tube being placed on 05/03/2021. The agency failed to update the care plan to address the abdominal tube and compression stockings with interventions, management and education. RECORD/PATIENT #2: Review of a fax from the wound care clinic dated 04/12/2021 showed: - The patient needs *foam* pads for left and right mid foot as well; - Apply moisturizing cream as needed for dry skin- NOT in wound or between toes; - Gentamicin (treats infections) 0.1% cream, apply to affected area daily. Apply to peritoneal dialysis (treatment for kidney failure that uses the lining of your abdomen to filter your blood inside the body) site with daily dressing change; Review of the plan of care dated 04/22/2021 failed to show the following: - Foam pads for left and right mid foot; - Peritoneal dialysis; - Gentamicin to peritoneal dialysis site; and - Moisturizing cream as needed for dry skin- not in wound or between toes. A home visit observation and interview on 05/04/2021 at 3:00 PM showed the patient had multiple boxes dialysis supplies in his/her room and he/she does peritoneal dialysis eight and a half hours every night. During an interview on 05/06/2021 at 9:31 AM, the clinical manager stated he/she expected any treatment staff are providing for patient and education to be included on the POC. Staff do not include every diagnosis, only the top five diagnosis with some sort of education and intervention.

G0590

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interview, the agency failed to alert the physician to changes in the patient's condition or needs that may suggest that the plan of care (POC) should be altered in, but not limited to, one (Record/Patient #1) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1 Record review of an occupational therapy initial evaluation visit note, dated 04/30/2021 at 8:15 AM, showed the patient recently had fluid drained off of his/her stomach and a drain has been placed for the future. The supervisor and physician had been contacted as a result of the visit. There was no further documentation. Record review of a skilled nursing visit note, dated 05/03/2021 at 12:36 PM, showed the patient has swelling to hands, calves, stomach, ankles, and feet. The patient stated swelling has gone down since paracentesis (procedure in which a needle or catheter is inserted into the peritoneal cavity to obtain ascetic fluid for diagnostic or therapeutic purposes). Supplies ordered for drain. There was no documentation of notification of physician or clinical manager as a result of this visit. Review of a skilled nurse visit note, dated 05/04/2021 at 10:20 AM showed upon assessment done this visit, noted peritoneal drain to abdomen placed; this was placed in interventional radiology (medical subspecialty that performs various minimally-invasive procedures using medical imaging guidance) last week for ascites (extra abdominal fluid). The registered nurse removed the gauze dressing to assess the site, minimal tan color drainage to old gauze. Mild erythema (redness) around insertion site, but appeared to be normal. "Called empty office for orders on drain management". The patient's caregiver reports he/she and family member were instructed on drain performance and have been draining the fluid daily without any complications. The registered nurse instructed caregiver that he/she will clarify orders and care. "Instructed to keep drain guys around two change daily, report any concerns for signs and symptoms of infection, including fever change and drainage increase redness or discomfort". The case manager left a "Cm" with oncologist and radiologist physician at the hospital. (The oncologist and radiologist were not the primary care physician listed on the POC). During home visit observation and interview on 05/04/2021 at 10:30 AM, the patient had an abdominal tube. The case manager changed the gauze dressing around the tube. The patient's caregiver stated "the abdominal tube was placed last Tuesday (04/27/2021), 5 liters of fluid was removed and a tube was inserted. They were instructed not to remove more than one liter of fluid at a time at home due to the possibility the patient's blood pressure could drop". The patient's caregiver said he/she would like to learn how to clean the tube and empty the drain. The case manager stated he/she found out about the tube being placed on 05/03/2021. There were orders for the drain that were sent home with the patient on how to manage drain and he/she had to clarify some of the orders with the "hospitalist" (a licensed physician who practices in a hospital and treats an array of conditions) and then he/she would update the plan of care. During an interview on 05/06/2021 at 9:48 AM, 10:35 and 11:28 AM, the clinical manager stated: - The case manager notified the radiologist (not listed as primary care physician on POC) that placed the tube on 05/01/2021 for orders and they were waiting for clarification; - The primary care physician will not address anything regarding infectious disease and the infectious disease physician will not deal with anything other than intravenous therapy; - There was no physician to oversee the care of the tube from which orders could be obtained; and - The agency followed the Condition of Participation/regulation to ensure the physician is notified to any changes in the patient's condition. As of the exit conference on 05/06/2021 at 1:15 PM, there was no additional information.

G0614

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information, home visit observation, and interview, the agency failed to ensure staff provided a written visit schedule to patients that included what discipline was visiting, and the frequency of visits in two (Record/Patient #1 and #2) of three home visits. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all patients served by the agency. Findings included: Review of the agency's untitled and undated policy related to Centers for Medicare and Medicaid Services (CMS) Conditions of Participation showed: - Apollo Home Health services will follow all CMS Conditions of Participation to include, but not limited to conditions of participation, pre-approval requirements, and other requirements that healthcare providers must meet to participate in Medicare. During an interview on 05/05/2021 at 12:45 PM, the clinical manager stated: - The agency followed the Condition of Participation/regulation to ensure schedules were left in the homes of visiting disciplines. RECORD/PATIENT #1: The plan of care (POC) dated 04/22/2021 through 06/20/2021 showed the physician ordered physical therapy to be provided to the patient one time a week for one week and then two times a week for three weeks beginning the week of 04/28/2021 through 05/22/2021. Review of the clinical record showed: Review of the admission packet during a home visit observation with ca/e manager A on 04/20/2021 at 1:00 PM, showed: - The patient rights and other information given to the patient during the initial visit contained the right to be advised in advance of the disciplines that will furnish care, and the frequency of proposed visits; and - The calendar showed the skilled nursing scheduled visits but there was no schedule or frequency for physical therapy. During an interview on 05/04/2021 at 10:30 AM, case manager A stated: - He/she writes his/her visits on the schedule in the folder; and - He/she said physical therapy had not filled out their schedule and frequency on the calendar. RECORD/PATIENT #2: The plan of care (POC) dated 03/28/2021 through 05/26/2021 showed the physician ordered skilled nursing one time a week for seven weeks beginning the week of 03/31/2021 through 05/15/2021 and speech therapy two times a week for three weeks beginning the week of 04/25/2021 through 05/15/2021. Review of the admission packet during a home visit observation with the speech therapist B on 05/04/2021 at 3:00 PM, showed: - The patient rights and other information given to the patient during the initial visit contained the right to be advised in advance of the disciplines that will furnish care, and the frequency of proposed visits; - A blank copy of a calendar to be used to record discipline visits for the patient/caregiver; and - Speech therapist B name and phone number was written on the outside of the admission folder and there was no visit schedule or frequency. During an interview on 05/04/2021 at 3:00 PM, speech therapist B said he/she writes his/her schedule on the outside of the admission folder. 622 Terri Based on home visit observation and interview, the agency failed to ensure the name and contact information of the home health agency clinical manager was listed in the admission packet of information left in patient homes. This affected three (Record/Patient #1, #2, and #3) of three applicable home visits. This deficient practice has the potential to affect all patients served by the agency. Findings Included: Review of the agency's untitled and undated policy related to Centers for Medicare and Medicaid Services (CMS) Conditions of Participation showed: - Apollo Home Health services will follow all CMS Conditions of Participation to include, but not limited to conditions of participation, pre-approval requirements, and other requirements that healthcare providers must meet to participate in Medicare.

G0622

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on home visit observation and interview, the agency failed to ensure the name and contact information of the home health agency clinical manager was listed in the admission packet of information left in patient homes. This affected three (Record/Patient #1, #2, and #3) of three applicable home visits. This deficient practice has the potential to affect all patients served by the agency. Findings Included: Review of the agency's untitled and undated policy related to Centers for Medicare and Medicaid Services (CMS) Conditions of Participation showed: - Apollo Home Health services will follow all CMS Conditions of Participation to include, but not limited to conditions of participation, pre-approval requirements, and other requirements that healthcare providers must meet to participate in Medicare. RECORD/PATIENT #1: A home visit observation on 05/04/2021 at 10:30 AM showed the admission packet of information left in the patient's home did not include the name and contact information of the home health agency clinical manager. RECORD/PATIENT #2: A home visit observation on 05/04/2021 at 3:00 PM showed the admission packet of information left in the patient's home did not include the name and contact information of the home health agency clinical manager. RECORD/PATIENT #3: A home visit observation on 05/04/2021 at 10:00 AM showed the admission packet of information left in the patient's home did not include the name and contact information of the home health agency clinical manager. During an interview on 05/05/2021 at 2:45 PM, the clinical manager stated: - The agency did not realize the clinical manager information should be left in the patient's admission packet of information; and - The agency followed the Condition of Participation regulations as a policy for the information to be left in the patient's homes.

G0682

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on policy review, record review, home visit observation, and interview, the agency failed to ensure staff followed infection control standards of practice in one (Record/Patient #1) of three home visit observations. This deficient practice has the potential to affect the health and safety of all patients served by the agency. Findings included: Review of the agency's policy titled, "Hand Hygiene", reviewed/updated 06/2020 showed: - Policy: To deliver safe services to our patients while reducing risk of cross contamination. To help clinicians maintain their health while delivering care to patients; - The use of gloves does not take the place of hand hygiene; - Hands must be washed after removing gloves that are visible contaminated with bodily fluids; and - Between glove change with dressing changes. RECORD/PATIENT #1`: Review of the patient's medical record showed no physician orders for an abdominal tube or abdominal tube care. During a home visit observation on 05/04/2021 at 10:30 AM, the case manager donned gloves and removed a gauze with tan drainage from the patient's abdominal tube. With the same gloved hands the case manager placed a new gauze around the patient's abdominal tube. During an interview on 05/06/2021 at 9:31 AM, the clinical manager said he/she would expect the clinical manager to change his/her gloves and wash his/her hand when going from a dirty area to a clean area. He/she agreed the case manager should have changed his/her gloves and washed his/her hands after removing the soiled dressing and placing the clean dressing.

G0686

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on policy review, employee file review, and interview, the agency failed to ensure a program was in place to properly monitor visitors who entered the home health agency for symptoms of COVID-19 and failed to ensure staff were provided infection control training annually for one (Employee # 3) of three employee files reviewed. This had the potential to affect infection control practices of all agency staff. Findings included: Review of the agency's undated policy titled "Infection Control - OSHA (Occupational Safety and Health Administration) Regulations" showed: - Universal precautions: All employees will utilize universal precautions for all patients in all situations; - The agency is responsible for reviewing and updating the policy annually, or more frequently if necessary, to reflect any new or modified tasks and procedures that affect occupational exposure and to reflect new or revised employee positions with occupational exposure; - Employee training: All employees receive initial and annual training conducted by the agency; - Training records are completed for each employee upon completion of training; - Everyone who works with or is potentially exposed to hazardous chemical will receive initial training on the hazard communication standard and this plan before starting work; and - Each new employee will attend a health and safety orientation. Review of the COVID-19 Focused Infection Control Survey guidance by CMS dated 12/20/2020 showed: - Entering the facility/agency visitor handling: Does the facility/agency have a screening process for those entering the facility (patients and visitors) to mitigate the risk of COVID-19 exposure, for example: exposure to COVID-19 screening questions and assessment of symptoms/illness. During surveyors' entrance to the agency on 05/03/2021 and 05/04/2021, no screening program was in place to monitor visitors/surveyors for symptoms of COVID-19. During an interview on 05/05/5021 at 9:00 AM, the administrator stated the agency did not have a screening program to monitor visitors to the agency for COVID-19 symptoms but all staff were monitored daily and patients were monitored with each staff visit. EMPLOYEE #3: Review of the employee file showed: - Position: Master social worker; - Date of hire: 03/10/2020; - No infection control training recorded in the file. During an interview on 05/06/2021 at 10:00 AM, the clinical manager and the administrator stated there was no recorded infection control training in Employee #3's employee file.

G0984

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on, review of Section 192.2490.12 RSMo, Section 192.2495 RSMo, Section 192.2495.6 RSMo, 192.3495.7 RSMo, agency policy, employee file review and interview, the agency failed to ensure all staff had the Employee Disqualification List (EDL) checked prior to hire and had the Family Care Safety Registry (FCSR) prior to patient contact in one (Employee #3) of three employee files reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of Section 192.2490.12 RSMo: "No person, corporation, or organization, or association who received the employee disqualification list under subdivisions (1) and (7) of subsection 11 of this section shall knowingly employ any person who is on the employee disqualification list." Review of Section 192.2495 RSMo, requires employees of licensed home health agencies under contract with the Missouri Department of Health and Senior Services, to register with the Family Care Registry, regardless of hire date. This section also requires home health agencies to conduct criminal background screenings by checking the Family Care Registry. Review of Section 192.2495.6, RSMo: "A provider is guilty of a Class A misdemeanor if the provider knowingly hires or retains a person to have contact with patients or residents and the person has been found guilty in this state or any other states or has been found guilty of a crime, which if committed in Missouri would be a Class A or B felony violation of Chapter 565, 566, or 569, or any violation of Subsection 4 of section 198.070 or section 568.020." Review of any Section 192.2495.7, RSMo (effective August 28, 2018): Any in-home services provider agency or home health agency shall be guilty of a Class A misdemeanor if such agency knowingly employs a person to provide in-home services or home health services to any in-home services client or home health patient and such person either refuses to register with the Family Care Safety Registry or if such person: - (1) Has any disqualifying factors listed in Subsection 6 of this section; - (2) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under Chapter 196 or 579; - (3) Has been found guilty of or pleaded guilty or nolo contendere to any felony offense under Section 568.045, 568.050, 568.175, 570.023, 570.030, 570.040, as it existed prior to January 1, 2017, 570.090, 570.145, 570.223, 575.230, or 576.080; - (4) Has been found guilty of or pleaded guilty or nolo contendere to a violation of Section 577.010 or 577.012 and who is alleged and found by the court to be an aggravated or chronic offender under Section 577.023; - (5) Has been found guilty of or pleaded guilty or nolo contendere to any offense requiring registration under Section 589.400; - (6) Is listed on the Department of Health and Senior Services Employee Disqualification List under Section 192.2490; - (7) Is listed on the Department of Mental Health Employee Disqualification Registry under Section 192.2490; and - (8) Has a finding on the Child Abuse and Neglect Registry under Sections 210.109 to 210.183." Review of the agency's policy titled "Recommended Hiring Process" revised May, 2020 showed background and reference check: Check the FCSR and run an EDL check and ask for three references. EMPLOYEE #3 (E3): Review of the employee's file showed: - Licensed as a master social worker; - Date of hire: 03/10/2020; - Date of first patient contact: 03/12/2020; - Failed to show EDL prior to hire, EDL dated 03/16/2020; and - Failed to show FCSR results obtained prior to first patient contact, FCSR date 03/16/2020. During an interview on 05/04/2021 at 3:30 PM, the administrator stated he/she did not know why the EDL and FCSR were dated after hire of E3 and the first patient contact date.

G1022

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on review of the agency's policy, review of the Condition of Participation: Clinical records 484.110 (a) (6), record review, and interview, the agency failed to ensure a comprehensive discharge summary was sent to the primary care practitioner or other health care professional who will be responsible for care to the patient after discharge within five business days of the patient's discharge in one (RECORD/PATIENT #5) of two discharge records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's untitled and undated policy related to Centers for Medicare and Medicaid Services (CMS) Conditions of Participation showed: - Apollo Home Health services will follow all CMS Conditions of Participation to include, but not limited to conditions of participation, pre-approval requirements, and other requirements that healthcare providers must meet to participate in Medicare. Review of the Condition of Participation: Clinical Records 484.110 states: - "The record must include a completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the home health agency (if any) within five business days of the patient's discharge," and - The interpretive guidelines states: Typically contains the following items: Admission and discharge dates, physician responsible for the home health plan of care (POC), reason for admission to home health, type of services provided and frequency of services, laboratory data, medications the patient is on at time of discharge, patient's discharge condition, patient outcomes in meeting the goals in the POC, and patient and family post-discharge instructions. RECORD/PATIENT#5: Review of the POC dated 03/03/2021 through 05/01/2021 showed: - Diagnoses include but not limited to: Diabetes mellitus (a disease in which your blood glucose, or blood sugar, levels are too high), chronic ulcer to right foot, and cellulitis (a common infection of the skin and the soft tissues underneath) - Skilled nursing 1 week 1 (1w1), 3 w 8 to perform intravenous administration of Vancomycin (a high powered antibiotic), care of a PICC (Peripherally Inserted Central Catheter, a thin, soft, long catheter (tube) that is inserted into a vein in the arm, leg or neck; the tip of the catheter is positioned in a large vein that carries blood into the heart; and is used for long-term IV antibiotics, nutrition or medications, and for blood draws) line; - Wound care, dressing change, IV dressing change/care and assessment; and - Lab work to be drawn. Review of the discharge summary dated 04/22/2021 showed: - Diagnoses and allergies included; - Labs were not included; - Reason for admission not included; - Last visit date: 04/14/2021; - Post discharge goals: Follow up with MD (medical doctor); and - Dated and electronically signed by the registered nurse on 04/22/2021 at 2:28 PM, completed and sent to the physician six days after the discharge date of 04/14/2021. During an interview on 05/06/2021 R 12:45 PM, the clinical manager stated: - The agency follows the CMS (Centers for Medicare and Medicaid Services) Conditions of Participation as a policy; - The discharge summary should have been sent within five days of the discharge date; - The summary was complete and a medication list was always sent with the summary; and - The date that the nurse completes the discharge summary is the date sent to the physician. Emergency Preparedness

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