Every finding on record at Aspire Home Healthcare of Arizona, Inc.

Emergency Preparedness HHA 42 CFR 484.102 Home Health The facility must meet all applicable Federal, State, and local emergency preparedness requirements as outlined in the Medicare and Medicaid Programs: Emergency Preparedness Requirements of Medicare and Medicaid Participating Providers and Suppliers Final Rule (81 FR 63860) March 04, 2019. Deficiencies were found at the time of the Medicare Recertification survey conducted from March 04, 2025 through March 06, 2025.

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), §485.542(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 interview, review of facility policies and procedures and review of facility documentation, it has been determined the facility has failed to update the emergency preparedness plan at least every 2 years. This deficient practice has the potential to negatively impact essential communication was well as ineffective responses during real emergencies risking harm to staff and patients. Findings include: Review of facility policy "...STANDARD: The Agency has written policies and procedures that outline the process for meeting patient needs in a disaster or crisis situation...." revealed, "...Evaluation of Emergency Management Plan...The company shall conduct an annual emergency practice drill, either in cooperation with or independent of community agencies to evaluate the adequacy of the plan. The Emergency Management Plan will be evaluated...." Review of facility policy "...Bomb Incident Plan...Approved By: Administrator, Effective...[no date], Revised: [no date]...Meet with [previous administrator identified] and police ...." Review of the Agency's Emergency Plan Binder and related documents revealed no evidence of an annual review. During interview with current Administrator verified the previous Administrator identified in policy is no longer employed by Agency and was unable to provide documentation to support Emergency Preparedness Plan was evaluated in the last year. Findings include: Review of facility policy "...STANDARD: The Agency has written policies and procedures that outline the process for meeting patient needs in a disaster or crisis situation...." revealed, "...Evaluation of Emergency Management Plan...The company shall conduct an annual emergency practice drill, either in cooperation with or independent of community agencies to evaluate the adequacy of the plan. The Emergency Management Plan will be evaluated...." Review of facility policy "...Bomb Incident Plan...Approved By: Administrator, Effective...[no date], Revised: [no date]...Meet with [previous administrator identified] and police ...." Review of the Agency's Emergency Plan Binder and related documents revealed no evidence of an annual review. During interview conducted on 03/05/205 with Employee #1, it was verified that the previous Administrator identified in policy is no longer employed by Agency and was unable to provide documentation to support Emergency Preparedness Plan was evaluated in the last year.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview, review of facility policies and procedures and review of facility documentation, it has been determined the facility has failed to develop and maintain an emergency preparedness plan based on the all-hazards facility and community-based risk assessments including strategies for addressing high risk emergency events identified by the risk assessments. This deficient practice has the potential to result in lack of preparedness and readiness to address the hazards most likely to affect a patient and staff population. Findings include: Review of the Agency's Emergency Plan Binder and related documents revealed no documentation to support strategies to address the high-risk emergency events identified in the Agency's Risk Assessment. During interview with Administrator, they confirmed all documentation related to Emergency Preparedness had been provided. Findings include: Review of the Agency's Emergency Plan Binder and related documents revealed no documentation to support strategies to address the high-risk emergency events identified in the Agency's Risk Assessment. During interview conducted on 03/05/2025 with Employee #1, they confirmed all documentation related to Emergency Preparedness had been provided.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on review of facility policies and procedures, review of facility documentation and interview, it has been determined the facility failed to develop a policy regarding the use of volunteers during an emergency. Failure to develop a policy regarding the use of volunteers during an emergency event can result in being unprepared for employees who wish to volunteer during a surge event or for the need to accept volunteer staff to address surge needs during an emergency event. In addition, this deficient practice as the potential to overwhelmed staffing resources, delay patient care as well as risking negative outcomes for those affected. Findings include: Review of Agency's Emergency Preparedness documentation presented failed to reveal policies and procedures around the use of volunteers or methods to address surge staffing needs. An interview with the Administrator confirmed Agency's need to adopt policy and procedures around surge staffing needs and the use of volunteers. Findings include: After reviewing the facility's Emergency Preparedness documentation, no documentation of policies and procedures around the use of volunteers or methods to address surge staffing needs. An interview conducted on 03/05/2025 with Employee #1 confirmed the facility need to adopt policy and procedures around surge staffing needs and the use of volunteers.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on review of policy and procedures, observation, and staff interview, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and is reviewed and updated at least every 2 years. The communication plan must include names and contact information for staff, entities providing services under arrangement, patients' physicians, and volunteers. Failure to provide contact information that could be needed during an emergency event in the facility communication plan can result in vital services being interrupted during an emergency event adversely impacting patient care. Findings include: The Emergency Preparedness documentation provided revealed no evidence of current staff names and contact information, entities providing services under arrangement, or current patient physician information. An interview with Administrator confirmed that the communication plan needs to be updated to include current staff names and contact information, entities providing services under arrangement and current patient physician information. Findings include: The Emergency Preparedness documentation provided revealed no evidence of current staff names and contact information, entities providing services under arrangement, or current patient physician information. An interview conducted on 03/05/2025 with Employee #1 revealed that the communication plan needs to be updated to include current staff names and contact information, entities providing services under arrangement and current patient physician information.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.542(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on review of policy and procedures, observation, and staff interview, it was determined that the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. The communication plan must include contact information for Federal, State, tribal, regional, local emergency preparedness staff, and other sources of assistance. This deficient practice has the potential to create confusion, delay timely communication, and increase risk to patient's for injury or illness during an emergency. Findings include: In the Emergency Preparedness documentation provided, reflects only hyperlinks to Tribal and Regional resources. During an interview with Administrator, they confirmed the communication plan needs to be updated to provide written contact information for Tribal and Regional resources. Findings include: In the Emergency Preparedness documentation provided, the documentation only reflects hyperlinks to Tribal and Regional resources. During an interview conducted on 03/05/2025 with Employee #1, it was confirmed the communication plan needs to be updated and provide written contact information for Tribal and Regional resources.

The following deficiencies were cited during the unannounced onsite Medicare Recertification survey conducted March 04, 2025, through March 06, 2025 with the requirements for 42 CFR Part 484 subparts A, B, and C requirements for a Home Health Agency. Three (3) home visits were conducted during the survey. Appendix Z, Emergency Preparedness was surveyed at the time of the Medicare Recertification, deficiencies were cited.

Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This ELEMENT is not met as evidenced by: Based on interview, review of facility policies and procedures and review of facility documentation, it has been determined the facility has failed to consider and accommodate any patient requests within the parameters of the assessment and plan of care, and the patient must be treated by the HHA as an active partner in the delivery of care. The HHA should make all reasonable attempts to respect the preferences of the patient regarding the services that will be delivered, such as the HHA visit schedule, which should be made at the convenience of the patient rather than of the agency personnel has the potential to lead to patient non-compliance and to worsened health outcomes. Findings include: Facility policy "...Care follows a written plan of care established and periodically reviewed by a doctor of medicine, osteopathy, or podiatric medicine..." revealed "...To assure that patient care needs are being addressed adequately and appropriately...All clinical services are implemented only in accordance with a plan of care established by a physician's written orders...." Facility policy "STANDARD: There are written policies and procedures established and implemented by the agency regarding the rights and responsibilities of patients...." revealed "...The Agency's policy and procedures reflect support of patients' rights to care, treatment and/or services within its capabilities, mission, and philosophy, and in compliance with applicable laws and regulations...All Agency representatives shall be knowledgeable of and uphold patients' rights and responsibilities, the policies and procedures pertaining to these rights, and shall assume responsibility for their implementation...Provide care, treatment and/or services by Agency representatives in a manner that respects and foster in patients/family members/caregivers a sense of dignity, positive self-regard, civil rights, and involvement in their care, treatment and services...." Review of patient #7 documentation dated April 5, 2024 in Agency EMR revealed, "...Missed Visit Form...Comments: Not available to do PT when this PT is available...." Review of patient #5 in Agency EMR revealed PT assessment to be completed by employee #7 due February 25, 2025 not completed as of March 6, 2025. Review of patient #5 in Agency EMR revealed MSW assessment to be completed by employee #4 due February 25, 2025 not completed as of March 6, 2025. In an interview with the Administrator, they acknowledged care should be provided per plan of care and Agency policies and procedures. Findings include: Facility policy "...Care follows a written plan of care established and periodically reviewed by a doctor of medicine, osteopathy, or podiatric medicine..." revealed "...To assure that patient care needs are being addressed adequately and appropriately...All clinical services are implemented only in accordance with a plan of care established by a physician's written orders...." Facility policy "STANDARD: There are written policies and procedures established and implemented by the agency regarding the rights and responsibilities of patients...." revealed "...The Agency's policy and procedures reflect support of patients' rights to care, treatment and/or services within its capabilities, mission, and philosophy, and in compliance with applicable laws and regulations...All Agency representatives shall be knowledgeable of and uphold patients' rights and responsibilities, the policies and procedures pertaining to these rights, and shall assume responsibility for their implementation...Provide care, treatment and/or services by Agency representatives in a manner that respects and foster in patients/family members/caregivers a sense of dignity, positive self-regard, civil rights, and involvement in their care, treatment and services...." Review of patient #7 medical record dated April 5, 2024 revealed, "...Missed Visit Form...Comments: Not available to do PT when this PT is available...." Review of patient #5 medical record revealed PT assessment to be completed by employee #7 due February 25, 2025 not completed as of March 6, 2025. Review of patient #5 medical record revealed MSW assessment to be completed by employee #4 due February 25, 2025 not completed as of March 6, 2025. In an interview conducted on 03/05/2025 with Employee #1, Employee #1 acknowledged that care should have been provided per plan of care and facility's policies and procedures.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on review of policy and procedures, observation, and staff interview, it was determined that the facility failed to document both the existence of the complaints and the resolution of the complaints. This deficient practice has the potential to lead to failure to demonstrate that it was received and addressed leading to a risking for legal challenges and lack of accountability. Findings include: Review of facility policy"...STANDARD HH7-7A.01, STANDARD HHA-7B.01 STANDARD: The Agency has written policies and procedures for identifying, monitoring, reporting, investigating, and documenting all incidents, accidents, variances or unusual occurrences involving personnel. All incidents, accidents, variances, or unusual occurrences are documented and reported. Reports are reviewed to collect and trend data on all incidents, accidents, and variances that occur...The incident report within 24 hours...the incident report is to be submitted to the employee's supervisor for review, investigation and response...Employee and/or patient related incidents are to be submitted to the Director of Patient Services within 48 hours of the occurrence, who will report the incident to the Administrator...The Administrator shall review the incident, determine if the occurrence could prove hazardous to other patients or company personnel, and initiate appropriate action to correct the problem...The incident report and all activities surrounding the occurrence are filed in a secure administrative file...." Review of facility Incident Tracking spreadsheet presented on March 04, 2025 at 1:17pm reflect last incident reported on September 23, 2019 at 9:19 am. Review of facility 2024 Quality Assurance and Performance Improvement (QAPI) minutes from 2024 reflect incidents not reflected on spreadsheet. During an interview with the administrator, additional tracking information was requested to support incidents reflected on 2024 QAPI meeting report. No evidence provided to support current incident tracking or any steps taken to identify issues to correct identified problems. Findings include: Review of facility policy"...STANDARD HH7-7A.01, STANDARD HHA-7B.01 STANDARD: The Agency has written policies and procedures for identifying, monitoring, reporting, investigating, and documenting all incidents, accidents, variances or unusual occurrences involving personnel. All incidents, accidents, variances, or unusual occurrences are documented and reported. Reports are reviewed to collect and trend data on all incidents, accidents, and variances that occur...The incident report within 24 hours...the incident report is to be submitted to the employee's supervisor for review, investigation and response...Employee and/or patient related incidents are to be submitted to the Director of Patient Services within 48 hours of the occurrence, who will report the incident to the Administrator...The Administrator shall review the incident, determine if the occurrence could prove hazardous to other patients or company personnel, and initiate appropriate action to correct the problem...The incident report and all activities surrounding the occurrence are filed in a secure administrative file...." Review of the facility's Incident Tracking spreadsheet presented on March 04, 2025 indicates that last incident reported was on September 23, 2019 at 9:19 am. Review of facility's 2024 Quality Assurance and Performance Improvement (QAPI) minutes from 2024 reflect incidents were not documented on spreadsheet. During an interview conducted on 03/04/2025 with Employee #1, additional tracking information was requested to support incidents reflected on 2024 QAPI meeting report. No evidence was provided on 03/04/2025 to support current incident tracking or any steps taken to identify issues to correct identified problems.

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on interview, review of facility policies and procedures and review of facility documentation, it has been determined the facility has failed to produce documentation for each complaint received that confirms that an investigation was conducted and records the investigation findings as well as the ultimate resolution of the complaint. This deficient practice has the potential to lead to failure to demonstrate that it was received and addressed leading to a risking for legal challenges and lack of accountability. Findings include: Agency policy, "...STANDARD: The Agency has written policies and procedures for identifying, monitoring, reporting, investigating, and documenting all incidents...All incidents, accidents, variances, or unusual occurrences are documented and reported. Reports are reviewed to collect and trend data on all incidents, accidents, and variances that occur...The Administrator shall review the incident, determine if the occurrence could prove hazardous to other patients or company personnel, and initiate appropriate action to correct the problem...All incidents, accident, variance and unusual occurrence reports are submitted to the Governing Board at least quarterly and more often as necessary depending on the severity of the incident and/or its impact on patient care/services or the Agency. The incident report and all activities surrounding the occurrence are filed in a secure administrative file...." Agency documentation provided on March 6, 2025 in QAPI binder reflected incidences in 2024. Incident report log provided reflected incidents through March 2019. Updated incident documentation was requested, but not provided. In interview with Administrator, they indicated that no incidents had been reported for 2025. Previous documentation regarding incidents for periods 2019-2024 was requested, but could not be provided. Findings include: Agency policy, "...STANDARD: The Agency has written policies and procedures for identifying, monitoring, reporting, investigating, and documenting all incidents...All incidents, accidents, variances, or unusual occurrences are documented and reported. Reports are reviewed to collect and trend data on all incidents, accidents, and variances that occur...The Administrator shall review the incident, determine if the occurrence could prove hazardous to other patients or company personnel, and initiate appropriate action to correct the problem...All incidents, accident, variance and unusual occurrence reports are submitted to the Governing Board at least quarterly and more often as necessary depending on the severity of the incident and/or its impact on patient care/services or the Agency. The incident report and all activities surrounding the occurrence are filed in a secure administrative file...." Documentation provided on March 6, 2025 in facility's QAPI binder revealed incidences documented in 2024. Incident report log provided by the facility reflected incidents through March 2019. Updated incident documentation was requested, but not provided. In a interview conducted on 03/06/2025 with Employee #1, it was indicated that no incidents had been reported for 2025. A request for documentation regarding incidents for periods 2019-2024 was requested, but could not be provided.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on review of policy and procedures, observation, and staff interview, it was determined that the facility failed to develop written policies and procedures that address influenza and pneumococcal vaccine administration, vaccination screening for safety exclusions, assessing contraindications prior to administration and managing adverse reactions. Failure to develop polices and procedures that address influenza and pneumococcal vaccines has the potential to result in increased morbidity and mortality from these preventable diseases, particularly in vulnerable populations. Findings include: Review of facility policies and procedures, Section 700 titled, "...Risk Management: Infection and Safety Control...." presented during survey failed to reflect written policies and procedures addressing influenza and pneumococcal vaccines. During interview with Administrator, it was confirmed the complete policies and procedures manual had been provided. Findings include: Review of facility policies and procedures, Section 700 titled, "...Risk Management: Infection and Safety Control...." presented during survey failed to reflect written policies and procedures addressing influenza and pneumococcal vaccines. During an interview conducted on 03/04/2025 with Employee #1, it was confirmed the complete policies and procedures manual had been provided at the time of the survey.

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 review of policy and procedures, observation, and staff interview, it was determined that the facility failed to ensure verbal orders are authenticated and dated by the physician or allowed practitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. Failure to obtain physician's signature has the potential to lead to incomplete or inadequate care and potentially medical errors. Findings include: Facility policy titled, "...Standard...There is evidence that the plan of care is reviewed by personnel involved in patient's care and attending physician at least once every 60 days...." revealed, "...Policy: When patients are referred to the Agency, the Agency will accept verbal physician orders communicated by a discharge planner, a nurse practitioner, physician's assistant or other authorized staff members, to be followed by written, signed and dated physician orders in order to expedite the delivery of home health services. Verbal orders are documented by the Registered Nurse/qualified therapist responsible for providing or supervising the ordered services, signed with his/her legal signature and credentials. Orders are to be signed by the physician within thirty (30) days of receipt of the order. Review of medical records for patient #2 and #7 reflect unsigned physician orders greater than 30 days. During Interview with administrator, they acknowledged orders unsigned by physician and reported staff working on getting signed orders. Findings include: Facility policy titled, "...Standard...There is evidence that the plan of care is reviewed by personnel involved in patient's care and attending physician at least once every 60 days...." revealed, "...Policy: When patients are referred to the Agency, the Agency will accept verbal physician orders communicated by a discharge planner, a nurse practitioner, physician's assistant or other authorized staff members, to be followed by written, signed and dated physician orders in order to expedite the delivery of home health services. Verbal orders are documented by the Registered Nurse/qualified therapist responsible for providing or supervising the ordered services, signed with his/her legal signature and credentials. Orders are to be signed by the physician within thirty (30) days of receipt of the order. Review of medical records for patient #2 and #7 reflect unsigned physician orders greater than 30 days. During an interview conducted on 03/04/2025 with Employee #1, Employee #1 acknowledged patient #2 and #7 orders were not signed by a physician.