Every finding on record at Ars Health Care, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey at the agency's new location: 12500 Riverside Drive Valley Village CA Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 44749, Health Facilities Evaluator Nurse Unduplicated Admissions - 30 Active Patients - 8 Sample Size - 10 Home Visits- 3

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review, the home health agency (HHA) failed to ensure the emergency preparedness plan/drill for 7 out of 7 field and office staff were completed in an annual basis. This failure had the potential to result of 7 out of 7 field and office staff lacking knowledge to respond effectively when an emergency/disaster situation occur. On 6/27/22 at 4:30 p.m., during a concurrent interview with the office manager and the DON stated they have not done any emergency drill for field and office staff. A review of the undated and unreviewed HHA's policy titled "Personnel Safety" indicated the HHA shall plan for a secure environment addressing security to protect staff and clients from potential harm. To maximize the personal safety of health care professionals working in the community and home setting, the agency will always provide education regarding safety for staff. A review of the undated and unreviewed HHA’s policy titled “Emergency and Disaster Preparedness Plan” indicated purpose is to establish guidelines for patient care during periods of an emergency or disaster that might disrupt home health service. To provide staff with direction and instruction in the event of an emergency. A review of the undated and unreviewed HHA’s policy titled “Home Safety: Patient’s Home Environment”, indicated a safety management In-service is given annually for all employees.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at the agency's new location: 12500 Riverside Drive Valley Village CA Representing the California Department of Public Health : Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 44749, Health Facilities Evaluator Nurse Unduplicated Admissions - 30 Active Patients - 8 Sample Size - 10 Home Visits- 3

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 interview and record review, the HHA failed to ensure the physician was notified on the new medication order, discontinued medications, and reviewed and clarified with the physician on the patient medication profile, for six out of eight sampled patients (Patient 2, 5, 6, 7, 8 and 9). This deficient practice had a potential for medication error. d. A review of Patient 5’s Plan of Care (POC) indicated a Start of Care (SOC)date of 5/18/22 for certification period 5/18/22 to 7/16/22, a 55-year-old female with the medical diagnosis of primary generalized osteoarthritis (osteoarthritis in which three or more joints or groups of joints are affected) and pain in right shoulder. A review of Patient 5’s Plan of Care indicated skilled nurse (SN) visits twice a week for two weeks and once a week for seven weeks. SN to perform every visit vital sign monitoring, assess and monitor for signs and symptoms for Covid-19 every visit/telehealth visit, assess pain severity/ location/character and effectiveness of pain control measures, monitor compliance with treatment regimen. POC indicated that Patient 5’s diet is no added salt, with low fat /low cholesterol. SN to teach effective breathing techniques, identify exacerbation of osteoarthritis disease process, implement pain relief measures, instruct patient and caregiver proper medication administration and to report side effects and adverse reactions, recognize idiopathic neuropathy(severe disease that impacts your ability to work), assess cardiovascular status, recognize signs and symptoms of hypertensive heart disease(a long-term condition that develops over many years in people who have high blood pressure), identify signs and symptoms of bleeding, emergency procedures and how to access 911. During a home visit with LVN 1 (Licensed Vocational Nurse 1) on 6/24/22 at 8:48 a.m., Patient 5 is alert, oriented to name. person and place. Patient 5 lives with husband and used a cane to ambulate inside the home and LVN 1 started her visit. During the medication review conducted with LVN 1 at 6/24/22 at 9:50 a.m., LVN 1 stated she called the pharmacy and call the office for new medication orders. LVN 1 stated she call the office receptionist to inform them of new orders. During an interview with the front desk receptionist of the HHA on 6/27/22 at 10:00 a.m., stated she deal with the calls, orders for (DME) durable medical equipment and medication orders from field staff and passes it to the office manager if she does not understand, she pass it to the office manager. On concurrent interview with the office manager confirmed that the front desk asks her what to do and he also tells her what to do. Office manager stated he oversee the day-to-day operations of the HHA. During an interview with the DON (Director of Nursing) on 6/27/22 at 12:25 p.m., DON stated that she call and verify all medication orders, discontinued or new to the pharmacy and update the patient’s medication profile in the chart. On concurrent record review of Patient 5’s medication profile, no documented evidence seen of new or discontinued medication orders in Patient 5’s chart. DON further stated that if it is not documented and verified with the physician it is considered a medication error. During an interview with the Pharmacist on 6/29/22 at 10:45 a.m., Pharmacist confirmed that two clerks receive the call from the HHA. Pharmacist further stated that two people who received the call are not licensed to verify physician’s orders and the pharmacist must verify and receive all medication orders. A review of the HHA’s document titled “Medication Profile” Policy No. 4-024.1 indicated that patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new and/or discontinued medications. A review of the HHA’s document titled “Administration and Documentation of Medications” indicated to provide guidelines for the safe administration of medications by licensed personnel. Licensed personnel will administer and document only those medications which have been ordered as part of the plan of care and have been approved for safe administration and monitoring during a home visit. a.A review of Patient 2's clinical record indicated a start of care (SOC) date of 06/14/22, with a diagnoses of intervertebral disc disorder (breakdown of one or more of the discs that separate and provide cushioning between the bones of the spine causing pain). A review of Patient 2's Plan of Care (POC) for the certification period of 06/14/22 to 08/12/22, included an order for Skilled Nursing (SN) to visit 2wk2, 1wk7. The POC further indicated for SN to monitor vital signs, Covid symptoms, and to manage symptoms of pain. On 06/24/22, at 9:45am. a joint home visit with Licensed Vocational Nurse (LVN 2) was conducted at Patient 2’s residence. A review of Patient 2’s Medication Profile provided by the agency, indicated Patient 2 had a physician's order for Naproxen (used to reduce inflammation and control mild pain), 500mg by mouth two times a day (BID) and was not available during home visit. During an observation of patient 2’s medication storage box, Tramadol (used to reduce inflammation and control mild pain),50mg was available but was not ion the patient’s medication profile and was on the Plan of Care (POC). During an interview on 6/24/22 at 10:35 a.m. LVN 2 stated, Naproxen 500mg was indicated on the patient’s POC, Tramadol 50mg was not on the POC. LVN 2 stated, for new or changes on medication, she would call the pharmacy to verify and confirm the medication order and would not call the physician for verification of new or changes on medication. During an interview and record review on 6/27/22 at 12:40 p.m., the Director of Patient Care Services (DPCS) Designee, stated, she was not aware of the change on the patient’s medication. DPCS Designee stated, she could not find the new order documented for the new medication. The DPCS stated it could be high risk for medication error.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure, to notify and verify the new and change of medication order before administration of medications for six out of 8 sampled patients (Patient 2, 5, 6, 7, 8, and 9). The agency’s licensed personnel did not call the physician to verify new or change of medication, would call the pharmacy, and verified all new and change of medication orders to the pharmacy and call the agency receptionist to report of the changes in mediation orders. This deficient practice resulted in patients not receiving medications as ordered and had a potential for medication error. d. A review of Patient 5’s Plan of Care (POC) indicated a Start of Care (SOC)date of 5/18/22 for certification period 5/18/22 to 7/16/22 , a 55 year old female with the medical diagnosis of primary generalized osteoarthritis (osteoarthritis in which three or more joints or groups of joints are affected) and pain in right shoulder. A review of Patient 5’s Plan of Care indicated skilled nurse (SN) visits twice a week for two weeks and once a week for seven weeks. SN to perform every visit vital sign monitoring, assess and monitor for signs and symptoms for Covid-19 every visit/telehealth visit, assess pain severity/ location/character and effectiveness of pain control measures, monitor compliance with treatment regimen. POC indicated that Patient 5’s diet is no added salt, with low fat /low cholesterol. SN to teach effective breathing techniques, identify exacerbation of osteoarthritis disease process, implement pain relief measures, instruct patient and caregiver proper medication administration and to report side effects and adverse reactions, recognize idiopathic neuropathy(severe disease that impacts your ability to work), assess cardiovascular status, recognize signs and symptoms of hypertensive heart disease(a long-term condition that develops over many years in people who have high blood pressure), identify signs and symptoms of bleeding, emergency procedures and how to access 911. During a home visit with LVN 1 (Licensed Vocational Nurse 1) on 6/24/22 at 8:48 a.m., Patient 5 is alert, oriented to name. person and place. Patient 5 live with husband and used a cane to ambulate inside the home and LVN 1 started her visit. During the medication review with LVN 1, noted the ff. medications listed on the medication profile: 1. Ibuprofen 600 milligrams (mg- a unit of measurement) 1 tablet by mouth twice daily 2. Fluticasone 50 micrograms(mcg) 1 spray into each nostril twice daily for allergies 3. Aspirin 81 milligrams 1 tablet once daily for stroke prophylaxis 4. Rosuvastatin 5 milligrams 1 tablet once at bedtime for high cholesterol 5. Vitamin D 50,000 international units one capsule once a week for Vitamin D deficiency 6. Atenolol 25 milligram 1 tablet once daily for high blood pressure 7. Dexilant 60 milligram 1 capsule once daily for stomach acidity 8. Escitalopram 10 milligram 1 tablet once daily for depression 9. Diclofenac 50 milligram 1 tablet twice a daily for pain LVN 1 stated patient had new medication orders that was sent by the pharmacy yesterday prior her visit dated 6/23/22 as follows: 1. Famotidine 40 milligrams 1 tablet daily stomach acidity 2. Diclofenac 1% gel apply 2 grams twice daily on affected areas such as shoulders, back, knee and elbow pain. On a concurrent interview with LVN 1 stated she always call the pharmacy to verify her new medication orders and always call the office of the new order. LVN 1 further stated that the front desk personnel of the HHA usually receives her new orders. When this writer asked LVN 1 the second time the process of verifying medication orders, LVN 1 stated again, she always calls the pharmacy and then the front desk to relay her new orders. During an interview with the front desk personnel on 6/27/22 at 10:00 a.m., stated that she receives the calls for all field staff regarding patient care, requests for durable medical equipment and medication clarification. Front desk personnel further stated, “If I need help, I call the office manager”. During a concurrent interview with the office manager on 6/27/22 at 10:00 a.m., office manager stated, “She calls me, and I tell her what to do.” Office manager further stated, “I manage the day-to-day operations of the agency.” A review of the Patient 5’s medical chart at the HHA on 6/27/22 at 9:30 a.m., indicated no documented evidence of Patient 5’s medications were transcribed and signed in a physician’s order form inside the patient’s chart. e. A review of Patient 6’s POC indicated an SOC date of 6/8/22 for certification period 6/8/22 to 8/6/22, an 85-year-old female with the medical diagnosis of primary generalized osteoarthritis and chronic obstructive pyelonephritis (renal inflammation and scarring induced by recurrent or persistent renal infection, vesicoureteral reflux, or other causes of urinary tract obstruction). A review of Patient 6’s POC indicated an order for SN visits twice a week for two weeks and once a week for seven weeks. SN to perform every visit vital sign monitoring, assess and monitor for signs and symptoms for Covid-19 every visit/telehealth visit, assess pain severity/ location/character and effectiveness of pain control measures, monitor compliance with treatment regimen. POC indicated that Patient 5’s diet is no added salt, with low fat /low cholesterol. SN to teach effective breathing techniques, identify exacerbation of osteoarthritis disease process, implement pain relief measures, instruct patient and caregiver proper medication administration and to report side effects and adverse reactions, recognize idiopathic neuropathy(severe disease that impacts your ability to work), assess cardiovascular status, recognize signs and symptoms of hypertensive heart disease(a long-term condition that develops over many years in people who have high blood pressure), assessment of musculoskeletal status, identify signs and symptoms of bleeding, emergency procedures and how to access 911. A review of HHA’s document titled “Drug Regimen Review” dated 6/8/22 indicated as follows: 1. Oxybutynin 5 mg 1 tablet by mouth once daily overactive bladder 2. Telmisartan 80 mg 1 tablet by mouth once daily for high blood pressure 3. Amlodipine 5 mg 1 tablet once daily for high blood pressure 4. Aspirin 81 mg 1 tablet by mouth once daily for stroke prophylaxis 5. Rosuvastatin 20 mg 1 tablet by mouth daily for high cholesterol 6. Levothyroxine 125 mcg 1 tablet by mouth once daily for underactive thyroid 7. Gabapentin 100 mg 1 tablet twice daily for pain 8. Vitamin D 50,000 International Units 1 capsule once weekly for Vitamin D deficiency 9. Esomeprazole 40 mg 1 capsule by mouth daily for stomach acidity 10. Valerian Root 1 tablet once daily for anxiety A review of the Patient 6’s medical chart at the HHA on 6/27/22 at 9:30 a.m., indicated no documented evidence of Patient 6’s medications were transcribed and signed in a physician’s order form inside the patient’s chart. Tylenol 500 mg 2 tablets every 8 hours as needed for pain f. A review of Patient 7’s POC indicated an SOC date of 6/14/22 for certification period 6/14/22 to 8/12/22, a 91-year-old female with the medical diagnosis of atherosclerotic heart disease (hardening of the arteries -- is the leading cause of heart attacks, strokes, and peripheral vascular disease) and asthma (is a condition in which your airways narrow and swell and may produce extra mucus. This can make breathing difficult). A review of Patient 7’s POC indicated an order for SN visits twice a week for two weeks and once a week for seven weeks. SN to perform every visit vital sign monitoring, assess and monitor for signs and symptoms for Covid-19 every visit/telehealth visit, assess pain severity/ location/character and effectiveness of pain control measures, monitor compliance with treatment regimen. POC indicated that Patient 5’s diet is no added salt, with low fat /low cholesterol. SN to teach effective breathing techniques, identify exacerbation of osteoarthritis disease process, implement pain relief measures, instruct patient and caregiver proper medication administration and to report side effects and adverse reactions, recognize idiopathic neuropathy(severe disease that impacts your ability to work), assess cardiovascular status, recognize signs and symptoms of hypertensive heart disease, assessment of musculoskeletal status, identify signs and symptoms of bleeding, emergency procedures and how to access 911. A review of HHA’s document titled “Medication reconciliation” dated 6/7/22 indicated as follows: 1. Aspirin 81 mg 1 tablet daily for stroke prophylaxis 2. Metoprolol succinate 25 mg 1 tablet daily for high blood pressure 3. Amlodipine 10 mg 1 tablet daily for high blood pressure 4. Ezetimibe 20 mg 1 tablet daily for high blood cholesterol 5. Esomeprazole 40 mg 1 tablet daily for stomach acidity 6. Lorazepam 0.5 mg 1 tablet daily as needed for anxiety 7. Furosemide 20 mg 1 tablet daily for high blood pressure 8. Symbicort 160/4.5 mg inhaler one puff twice daily for difficulty breathing 9. Dramamine 50 mg every 4 to 6 hours as needed for nausea A review of the Patient 7’s medical chart at the HHA on 6/27/22 at 9:30 a.m., indicated no documented evidence of Patient 7’s medications were transcribed and signed in a physician’s order form inside the patient’s chart. g. A review of Patient 8’s POC indicated an SOC date of 6/15/22 for certification period 6/15/22 to 8/13/22, a 65-year-old female with the medical diagnosis of atherosclerotic heart disease (hardening of the arteries -- is the leading cause of heart attacks, strokes, and peripheral vascular disease) and asthma (is a condition in which your airways narrow and swell and may produce extra mucus. This can make breathing difficult). A review of Patient 8’s POC indicated an order for SN visits twice a week for two weeks and once a week for seven weeks.PT (Physical Therapy) evaluation with frequency, SN to perform every visit vital sign monitoring, assess and monitor for signs and symptoms for Covid-19 every visit/telehealth visit, assess pain severity/ location/character and effectiveness of pain control measures, monitor compliance with treatment regimen. POC indicated that Patient 5’s diet is no added salt, with low fat /low cholesterol. SN to teach effective breathing techniques, identify exacerbation of osteoarthritis disease process, implement pain relief measures, instruct patient and caregiver proper medication administration and to report side effects and adverse reactions, recognize idiopathic neuropathy, assess cardiovascular status, recognize signs and symptoms of hypertensive heart disease, assessment of musculoskeletal status, identify signs and symptoms of bleeding, emergency procedures and how to access 911. PT for bed mobility and transfers, therapeutic exercises, balance and endurance training, muscle and movement reduction and joint mobilization. A review of HHA’s document titled “Drug Regimen Review” dated 6/15/22 indicated Patient 8’s medication as follows: 1. Alendronate 70 mg 1 tablet once weekly for brittle bones 2. Meloxicam 15 mg 1 tablet once daily for pain 3. Vitamin D2 1.25 mg 1 capsule by mouth weekly for Vitamin D deficiency 4. Atorvastatin 20 mg 1 tablet once daily for high cholesterol 5. Omega 3 acid 500 mg 1 capsule by mouth twice daily for supplement 6. Lidocaine 5% patch apply topically every 12 hours for pain, indicated no documented evidence of Patient 7’s medications were transcribed and signed in a physician’s order form inside the patient’s chart. A review of the Patient 8’s medical chart at the HHA on 6/27/22 at 9:30 a.m., indicated no documented evidence of Patient 8’s medications were transcribed and signed in a physician’s order form inside the patient’s chart. h. A review of Patient 9’s POC indicated an SOC date of 5/17/22 for certification period 6/15/22 to 8/13/22, a 77-year-old female with the medical diagnosis of primary generalized osteoarthritis and presence of artificial knee joint. A review of Patient 9’s POC indicated an order for SN visits twice a week for two weeks and once a week for seven weeks. SN to perform every visit administration of cyanocobalamin 1000 microgram per milliliter intramuscular once monthly, observing infection control measures and safe disposal of needles/ contaminated supplies, vital sign monitoring, assess and monitor for signs and symptoms for Covid-19 every visit/telehealth visit, assess pain severity/ location/character and effectiveness of pain control measures, monitor compliance with treatment regimen. POC indicated that Patient 5’s diet is no added salt, with low fat /low cholesterol. SN to teach effective breathing techniques, identify exacerbation of osteoarthritis disease process, implement pain relief measures, instruct patient and caregiver proper medication administration and to report side effects and adverse reactions, recognize idiopathic neuropathy, assess cardiovascular status, recognize signs and symptoms of hypertensive heart disease, assessment of musculoskeletal status, identify signs and symptoms of bleeding, emergency procedures and how to access 911. A review of Patient 9’s document titled “Medication Reconciliation” dated 5/12/22 indicated the following medications: 1. Cyanocobalamin inject intramuscular usually every other month for Vitamin B deficiency 2. Loratadine 10 mg daily for allergies 3. Vitamin D 50,000 weekly for Vitamin d deficiency 4. Olopatadine 0.2% 1 drop on both eyes daily for allergies 5. Clotrimazole beta 1% /0.05 antifungal cream 6. Magoxide 400mg twice daily for high blood pressure 7. Rosuvastatin Calcium 10 mg daily for high cholesterol 8. Nexium 40 mg daily for stomach acidity 9. Vascepa 1 gram three times a day for high cholesterol 10. Risedronate Sodium 35mg every week for brittle bones 11. HCTZ 12.5 mg daily for high blood pressure 12. Lisinopril 10 mg daily for high blood pressure 13. Levothyroxine 75 mg 14. Zolpidem tart 5 mg daily 15. Pennsaid 2% 2 pumps twice daily A review of the Patient 9’s medical chart at the HHA on 6/27/22 at 9:30 a.m., indicated no documented evidence of Patient 9’s medications were transcribed and signed in a physician’s order form inside the patient’s chart. During an interview with the Director of Patient Care Services (DPCS) on 6/27/22 at 12:25 p.m., DPCS stated that they verify medication orders with the pharmacy and then write it on the medication profile. DPCS further stated that it is a medication error if the discontinued and or new medications were not transcribed in a physician’s order form. A review of the HHA’s undated document titled “Order for Medication and Treatment” indicated medication and treatment orders must be ordered by the patient’s physician to be carried out by the skilled agency personnel. No medication or treatment can be given except if there is a signed order. The order can be given over the phone by the physician and administered by the skilled nursing staff. All initial and following orders must be documented and signed within 30 days. All orders must be incorporated in the patient’s medical record. All telephone orders can only be taken by licensed personnel and shall be recorded immediately in the patient’s medical record and must be signed by both the skilled nursing and ordering physician. A review of the HHA’s undated document titled “Drug Regimen review” indicated that any changes in medications, such as changes in medication dosage, new medications or stopped medications should be documented in a physician order, countersigned by the clinician who received the order and the attending physician.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency's governing body failed to ensure an ongoing program for Quality Assurance Performance Improvement (QAPI) that addressed improvement efforts on improved quality of care and patient safety. A review of the agency's Quality Assurance and Performance Improvement (QAPI) projects presented by the office manager, indicated that the agency had done the same lesson plan for QAPI back in 2021.There was no documented evidence that the HHA reevaluated their lesson plan for improved quality of care and patient safety and no documented evidence for 2022. During an interview on 6/27/22 at 10:00 a.m., the office manager stated that he copied the same lesson plan from 2021. The office manager stated that since the new Director of Patient Care Services (DPCS) and the new Administrator started they have not done any QAPI activities. The office manager also stated that the DPCS should do the QAPI program. On 6/27/22 at 12:25 p.m., during an Interview, the DPCS stated the QAPI meeting is done once a month or three times in a quarter. During concurrent review of the QAPI binder presented by the office manager indicated no documented evidence of QAPI meetings and /or Governing Body minutes done by the HHA. A review of the HHA's Policy No. 1-002.1 titled, "Governing Body" indicated the governing body would assume full legal authority, responsibility, decision making ang accountability for the overall management and operations, the provision of services, fiscal operations, human resource management, review of the organization's budget and operational plans, and its quality assessment and performance improvement (QAPI) program. The governing body of ARS Health Care Inc. would serve as the governing authority for the home care program, which will function according to ARS Health Care Inc's by laws. The Governing Body would authorize adequate resources and support to establish and maintain an organization-wide performance improvement program. Information related to the performance improvement program would be provided to the Governing Body. The governing Body would appoint a corporate compliance officer who is responsible for the day to day oversight of the Corporate Compliance program and coordination of all compliance initiatives. The Corporate compliance Officer would report to the CEO/Administrator and the Governing Body.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the hospice agency failed to follow the standards of practice to prevent spread of COVID-19 (Coronavirus 19 disease, a highly, contagious respiratory illness caused by virus that spread from person to person) by failing to: 1. Have procedures for symptoms screening for COVID-19 for the staff and visitor who enter in the home health agency as indicated in the Centers for Disease Control and Prevention (CDC). This deficient practice placed the patients and staff, and/or visitors at risk for COVID-19 and further spread of infection that could lead to severe respiratory illness, hospitalization and/or death. During observation on 6/23/22 at 11:20 a.m., upon entrance to the HHA, there was no procedures to screen for Covid-19 symptoms. During observation on 6/27/22 at 10:00 a.m., upon entrance to the HHA, there was no procedures to screen for Covid-19 symptoms. On 6/27/22 at 12:25 p.m., during a concurrent interview with the office manager and the Director of Patient Care Services (DPCS), they stated they do not come to the office often and they don’t screen field staff because they do not come to the office. The office manager stated most of the time there is only one person inside the office. The DPCS stated they do not have any patients infected with Covid-19. A review of the HHA’s policy titled, “Infection Control Program” undated and unrevised, indicated the agency’s infection control program is designed to lower the risks and improve the rates of employee and patient organization-acquired infections. The agency implements policies and procedures to prevent the occurrence or spread of infection. A review of the Centers for Disease Control and Prevention (CDC)'s Interim Infection Control Recommendation for Healthcare Personnel during COVID-19 Pandemic updated 2/2/22 indicated to establish a process to identify and manage individuals with suspected or confirmed COVID-19 regardless of vaccination status including options that could include individual screening on arrival at the facility or implementing electronic monitoring system in which the individual can self-report before entering the facility.

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 observation, record review and interview, the home health agency (HHA) failed to provide infection control education to seven of seven staff regarding procedures for screening for COVID-19 symptoms (Coronavirus 19 disease, a highly, contagious respiratory illness caused by virus that spread from person to person). This deficient practice placed the patients, staff, and/or visitors at risk for COVID-19 and further spread of infection that could lead to severe respiratory illness, hospitalization and/or death. During observation on 6/23/22 at 11:20 a.m., upon entrance to the HHA, there was no screening for Covid-19 symptoms. During observation on 6/27/22 at 10:00 a.m., upon entrance to the HHA, there was no screening for Covid-19 symptoms. On 6/27/22 at 12:25 p.m., during an interview, the Director of Patient Care Services (DPCS) stated that they did not have infection control In service to the staff since she started working for the agency since May 2022. The DON also stated that they were to follow the monthly in-service topics as scheduled. On concurrent review of the HHA’s document on in-service attendance record indicated no documented evidence for Infection control in-service to the staff working in the office and in the field. A review of the HHA's document on In service attendance record indicated no evidence for infection control in-service for seven of seven office and field staff. A review of the HHA's infection control log on 6/27/22 at 12:30 p.m., indicated that the HHA did not perform infection control in-service for the past three years. A review of the undated and unreviewed HHA's document titled "Infection Control Plan", indicated that education of staff in infection control is required at orientation and annually.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on observation, and interviews, the home health agency failed to ensure the agency had an Administrator designee when the Administrator (a person who oversee the day-to-day administrative operations of the healthcare facilities with responsibilities of planning and supervising all medical services, including monitoring budgets and updating health records) is unavailable. This failure had the potential for the agency's poor quality management which can affect the quality of care and services provided by staffs to all the patients under their care. During a phone interview on 6/23/2022 at 12:20 p.m., the newly hired Administrator stated, "I just submitted my application and credentials to the office manager and I am not supposed to be there everyday. I am not aware that I have a designee and I am not able to go today." During an interview with the office manager on 6/27/2022 at 10:00 a.m., office manager stated “I oversee everything here.” During an interview on 6/27/2022 at 12:25 p.m., the Director of nursing (DON) stated, "I am here three times a week only, Mondays, Wednesdays and Fridays only in the afternoon. If they need me they call me." On 6/27/2022 at 12:30 p.m., during the exit conference, the administrator was not present and was not available over the phone.