Every finding on record at Associated Family Home Care, Inc.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted March 12 through March 14, 2024, Associated Family Home Care, Inc. was found not to be in compliance with the following requirement of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the agency policies and procedures and documentation, and based on interview with the administrator (Employee #9), the agency failed to ensure emergency preparedness exercises were conducted for three (3) of three (3) years beginning 2021. (2021, 2022 and 2023) Findings Include: On March 12, 2024 at approximately 12:35 PM, review of the "All Hazard Emergency Preparedness Policy" revealed the following under "Drills": Agency staff will participate in an annual desktop drill to determine the effectiveness and efficiency of the current policy and any forms developed for use in a disaster. On March 12, 2024 at approximately 11:44 AM, review of Governing Body meeting minutes dated 12/15/2023 revealed the category of emergency preparedness. On March 13, 2024 at approximately 8:20 AM, review of PA DOH ERS report documentation revealed the agency's emergency preparedness plan was activated in March 2020 due to COVID-19. On March 12, 2024 at approximately 12:35 PM, review of the emergency preparedness binder failed to reveal that an emergency preparedness exercise (full-scale community-based, facility-based functional, mock disaster drill or tabletop exercise) had been conducted in 2021, 2022 or 2023. During interview conducted on March 14, 2024 at approximately 4:00 PM, the administrator confirmed emergency preparedness exercises were not conducted in 2021, 2022 nor 2023.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted March 12 through March 14, 2024, Associated Family Home Care, Inc. was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 agency policies/procedures, documentation and clinical records, and based on interview with the supervising registered nurse (RN-Employee #8) and the administrator (Employee #9), the agency failed to ensure written instructions regarding the visit frequency were provided to five (5) of five (5) patients for whom a home visit was conducted. (Patients #1, #2, #3, #4 and #5) Findings include: On March 14, 2024 at approximately 3:40 PM, review of the agency policy titled "Patient Rights and Responsibilities" revealed the following under "Rights of the Patient": Participated in, be informed about...(v) The frequency of visits... On March 14, 2023 at approximately 3:42 PM, review of the agency policy titled "Patient Care Planning Policy" revealed the following: The 485 (Home Health Certification and Plan of Care) will be designed to meet patient's medical needs based on physician orders and patient's participation in their care. Patient #1: On March 14, 2024 at approximately 9:28 AM, review of the clinical record revealed skilled nursing (SN) services are to be provided one (1) time a week for one (1) week, followed by three (3) times a week for one (1) week then one (1) time a week for eight (8) weeks as ordered on the "Home Health Certification and Plan of Care" for the initial certification period of February 17 through April 16, 2024. Review of verbal order documentation revealed the SN visit frequency was increased to three (3) times a week. Review of the initial physical therapy (PT) evaluation note revealed PT services are to be provided two (2) time a week for four (4) weeks effective 02/20/2024. Review of the initial occupational therapy (OT) evaluation note revealed OT services are to be provided two (2) times a week for four (4) weeks effective 02/20/2024. Review of the OT re-evaluation note revealed OT services were to continue two (2) times a week for four (4) weeks effective 03/11/2024. During a home visit conducted on March 13, 2024 at approximately 9:00 AM, review of the agency's admission folder failed to reveal written instructions were provided to the patient regarding the SN, PT and OT visit frequency. Patient #2: On March 14, 2024 at approximately 10:13 AM, review of the clinical record revealed SN services are to be provided one (1) time a week for one (1) week, followed by two (2) times a week for one (1) week then one (1) time a week for seven (7) weeks as ordered on the "Home Health Certification and Plan of Care" for the initial certification period of February 2 through April 1, 2024. Review of the initial PT evaluation note revealed PT services are to be provided two (2) time a week for four (4) weeks effective 02/07/2024. Review of the PT re-evaluation note revealed PT services were to continue two (2) times a week for four (4) weeks effective 03/04/2024. Review of the initial OT evaluation note revealed OT services are to be provided two (2) times a week for four (4) weeks effective 02/07/2024. Review of the OT re-evaluation note revealed OT services were to continue two (2) times a week for four (4) weeks effective 03/04/2024. During a home visit conducted on March 13, 2024 at approximately 9:50 AM, review of the agency's admission folder failed to reveal written instructions were provided to the patient regarding the SN, PT and OT visit frequency. Patient #3: On March 14, 2024 at approximately 10:41 AM, review of the clinical record revealed SN services are to be provided one (1) time a week for one (1) week for nine (9) weeks as ordered on the "Home Health Certification and Plan of Care" for the recertification period of January 27 through March 26, 2024. During a home visit conducted on March 13, 2024 at approximately 10:50 AM, review of the agency's admission folder failed to reveal written instructions were provided to the patient regarding the SN, visit frequency. Patient #4: On March 14, 2024 at approximately 10:57 AM, review of the clinical record revealed SN services are to be provided one (1) time a week for one (1) week, followed by two (2) times a week for one (1) week then one (1) time a week for seven (7) weeks as ordered on the "Home Health Certification and Plan of Care" for the initial certification period of February 28 through April 27, 2024. Review of the initial OT evaluation note revealed OT services are to be provided two (2) times a week for four (4) weeks effective 03/04/2024. Review of verbal order documentation dated 03/04/3034 revealed home health aide (HHA) services are to be provided two (2) time a week for eight (8) weeks. During a home visit conducted on March 13, 2024 at approximately 12:00 PM, review of the agency's admission folder failed to reveal written instructions were provided to the patient regarding the SN , OT and HHA visit frequency. Patient #5: On March 14, 2024 at approximately 11:18 AM, review of the clinical record revealed SN services are to be provided two (2) times a week for one (1) week followed by one (1) time a week for eight (8) weeks as ordered on the "Home Health Certification and Plan of Care" for the initial certification period of March 4 through May 2, 2024. During a home visit conducted on March 13, 2024 at approximately 1:00 PM, review of the agency's admission folder failed to reveal written instructions were provided to the patient regarding the SN visit frequency. During interview conducted on March 14, 2024 at approximately 4:00 PM, the supervising RN (Employee #8) and the administrator (Employee #9) confirmed written instructions regarding the above referenced visit frequencies had not been provided to the above identified patients.

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 review of agency policies/procedures, documentation and clinical records, and based on interview with the supervising registered nurse (RN-Employee #8) and the administrator (Employee #9), the agency failed to ensure written instructions regarding the medication schedule and instructions were provided to four (4) of five (5) patients for whom a home visit was conducted. (Patients #1, #2, #4 and #5) Findings include: On March 14, 2023 at approximately 3:42 PM, review of the agency policy titled "Patient Care Planning Policy" revealed the following: The 485 (Home Health Certification and Plan of Care) will be designed to meet patient's medical needs based on physician orders and patient's participation in their care, Patient #1: On March 14, 2024 at approximately 9:28 AM, review of the clinical record revealed a total of four (4) medication orders were included on the "Home Health Certification and Plan of Care" for the initial certification period of February 17 through April 16, 2024. During a home visit conducted on March 13, 2024 at approximately 9:00 AM, review of the agency's admission folder failed to reveal written instructions were provided to the patient regarding the medication schedule and instructions for the medications ordered on the initial "Home Health Certification and Plan of Care". Patient #2: On March 14, 2024 at approximately 10:13 AM, review of the clinical record revealed a total of 21 medication orders were included on the "Home Health Certification and Plan of Care" for the initial certification period of February 2 through April 1, 2024. During a home visit conducted on March 13, 2024 at approximately 9:50 AM, review of the agency's admission folder failed to reveal written instructions were provided to the patient regarding the medication schedule and instructions for the medications ordered on the initial "Home Health Certification and Plan of Care". Patient #4: On March 14, 2024 at approximately 10:57 AM, review of the clinical record revealed a total of 18 medication orders were included on the "Home Health Certification and Plan of Care" for the initial certification period of February 28 through April 27, 2024. During a home visit conducted on March 13, 2024 at approximately 12:00 PM, review of the agency's admission folder failed to reveal written instructions were provided to the patient regarding the medication schedule and instructions for the medications ordered on the initial "Home Health Certification and Plan of Care". Patient #5: On March 14, 2024 at approximately 11:18 AM, review of the clinical record revealed a total of 18 medication orders were included on the "Home Health Certification and Plan of Care" for the initial certification period of March 4 through May 2, 2024. During a home visit conducted on March 13, 2024 at approximately 1:00 PM, review of the agency's admission folder failed to reveal written instructions were provided to the patient regarding the medication schedule and instructions for the medications ordered on the initial "Home Health Certification and Plan of Care". During interview conducted on March 14, 2024 at approximately 4:00 PM, the supervising RN (Employee #8) and the administrator (Employee #9) confirmed written instructions regarding medication schedule and instructions had not been provided to the above identified patients.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, home visit observation and based on interview with agency staff (Employee #1), the supervising registered nurse (RN-Employee #8) and the administrator (Employee #9), the agency failed to ensure written instructions regarding the type of treatments to be provided by skilled nursing (SN) were provided to three (3) of three (3) patients for whom the "Home Health Certification and Plan of Care" and/or interim physician orders included wound care orders. (Patients #1, #2 and #3) Findings include: On March 14, 2024 at approximately 3:40 PM, review of the agency policy titled "Patient Rights and Responsibilities" revealed the following under "Rights of the Patient": Participated in, be informed about...(ii) The care to be furnished... On March 14, 2023 at approximately 3:42 PM, review of the agency policy titled "Patient Care Planning Policy" revealed the following: The 485 (Home Health Certification and Plan of Care) will be designed to meet patient's medical needs based on physician orders and patient's participation in their care. Patient #1: On March 14, 2024 at approximately 9:28 AM, review of the clinical record revealed the following wound care orders were obtained on 03/06/2024: Bilateral (both) buttocks to be cleansed with soap and water or normal saline solution (NSS), skip prep (protectant) to surrounding skin, apply Silvasorb gel (wound treatment) to bed of wounds, cover with Optifoam dressing; skilled nursing to change three (3) times a week and as needed. Review of SN visit note documentation revealed wound assessment and care were performed/provided during the SN visits performed on 03/06, 03/08 and 03/11/2024. During a home visit conducted on March 13, 2024 at approximately 9:00 AM, an interview conducted with the licensed practical nurse (Employee #1) revealed written instructions regarding wound care are provided if a caregiver is available to perform wound care. The LPN reported that a caregiver was not available to provide wound care for patient #1. Review of the agency's admission folder failed to reveal written instructions had been provided to the patient regarding the wound care orders obtained on 03/06/3034. Patient #2: On March 14, 2024 at approximately 10:13 AM, review of the clinical record revealed the following wound care orders were obtained on 02/21/2024: Bilateral lower extremities: Cleanse with soap and water, pat dry, apply Silvadene (wound treatment) and ace bandages. Review of SN visit note documentation revealed wound assessment and care were performed/provided during the SN visits performed on 02/27, 03/04 and 03/11/2024. During a home visit conducted on March 13, 2024 at approximately 9:50 AM, review of the agency's admission folder failed to reveal written instructions had been provided to the patient regarding the wound care orders obtained on 02/21/2024. Patient #3: On March 14, 2024 at approximately 10:41 AM, review of the clinical record revealed the following wound care orders were included on the "Home Health Certification and Plan of Care" for the recertification period of January 27 through March 26, 2024: Left and right abdominal wounds to be cleansed with NSS, then acetic acid wet to dry dressing to abdominal dehiscence (wound/incision edges which have reopened), apply acetic acid above area of wound dehiscence, cover with dry sterile dressing and secure with tape twice a day. Skin prep to skin surrounding wounds. During a home visit conducted on March 13, 2024 at approximately 10:50 AM, the RN (Employee #3) provided wound care to the abdominal wounds, Review of the agency's admission folder failed to reveal written instructions had been provided to the patient regarding the wound care orders included on the "Home Health Certification and Plan of Care". During interview conducted on March 14, 2024 at approximately 4:00 PM, the supervising RN (Employee #8) and the administrator (Employee #9) confirmed written instructions regarding the above referenced wound care orders had not been provided to the above identified patients.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on the review of agency policies/procedures, clinical records, personnel files and a Nursing2024 publication, and based on interview with the supervising registered nurse (RN-Employee #8) and the administrator (Employee #9), the agency failed to ensure documentation was maintained in the personnel file which provided evidence three (3) of three (3) registered nurses (RN) completed a demonstration to determine competency for maintenance and care of tunneled central venous catheters (CVC-intravenous line which can be inserted into a vein in the chest) and/or maintenance and care and/or removal of peripherally inserted central catheters (PICC-intravenous line which is inserted into a vein in the arm.). (Employees #3, #10 and #11) Findings include: On March 14, 2024 at approximately 3:41 PM, review of the agency policy titled "Staff Selection, Competency, and Qualifications Policy" revealed the following under guidelines: 8. All individuals will demonstrate competency for any technology required in the care/services of clients by the completion of proficiency checklists. On March 14, 2024 at approximately 3:44 PM, review of the agency policy titled "Staff Credentialing/Certification Policy revealed the following: General Statement: It is the policy of this agency to identify guidelines for staff requirements pertaining to those staff members providing high tech therapies in the home setting... PICC Certification...2. Competency will be measured during the orientation period by experienced staff members or prior to being scheduled to perform skill alone. On March 12, 2024 at approximately 3:50 PM, review of the "Nursing2024" article titled "How to Remove a PICC with Ease" (https://journals.lww.com/nursing/citation/2002/05000/how_to_remove_a_picc_with_ease.27.aspx) revealed the following: Inspect the PICC...measure its length... During interview conducted on March 14, 2024 at approximately 3:02 PM, the supervising RN (Employee #8) confirmed the external length of the PICC line is to be measured with each PICC line dressing change. Patient #8: On March 14, 2024 at approximately 12"35 PM, review of the clinical record revealed the registered nurse (RN-Employee #10) identified the right chest central venous catheter (CVC) intravenous (IV) line as a PICC line (IV line which is inserted into a vein in the arm) as evidenced by the documentation included on "Home Health Certification and Plan of Care" for the initial certification period of 02/02/2024 through 04/01/2024, the start of care SN note dated 02/02/2024 and the SN note dated 02/05/2024. Review of SN note documentation revealed the RN (Employee #10) provided site care to the right chest CVC on 02/05, 02/08, 02/15 and 02/22/2024. Patient #10 (Discharge): On March 14, 2024 at approximately 1:56 PM, review of the clinical record revealed the following was documented related to the right arm PICC line: -On 12/04, 12/06 and 12/11/2023, the RN (Employee #10) performed PICC line dressing change but the RN failed to assess the external length of the PICC line. On during the first SN visit on 12/26/2023 and during the SN visit on 01/02/2024, the RN (Employee #11) performed PICC line dressing change but the RN failed to assess the external length of the PICC line. -On 12/18/2023, the RN (Employee #11) documented the external length of the PICC line was five (5) centimeters (cm). On 12/26/2023, a second SN visit was performed due to PICC line complications. During the second SN visit on 12/26/2023, the RN (Employee #3) documented the external length of the PICC line was 1.0 cm. -On 01/08/2024, the RN (Employee #10) discontinued (removed) the PICC line but there was no documentation the PICC length was measured after removal. Between March 13, 2024 at approximately 1:47 PM and March 14, 2024 at approximately 3:12 PM, review of personnel file documentation revealed the following: Employee #3: The date of hire of the RN was 04/29/2014. Review of the "Infusion Skills Checklist" and the "Nursing Skills Proficiency Checklist" forms dated 04/29/2014 failed to reveal that a competency demonstration was completed for PICC line maintenance and care. Employee #10: The date of hire of the RN was 11/06/2017. Review of the "Infusion Skills Checklist" and the "Nursing Skills Proficiency Checklist" forms dated 11/07/2017 failed to reveal that a competency demonstration was completed for CVC and PICC line maintenance and care nor PICC line removal. Employee #11: The date of hire of the RN was 11/17/2015. Review of the "Infusion Skills Checklist" and the "Nursing Skills Proficiency Checklist" forms dated 11/17/2025 failed to reveal that a competency demonstration was completed for PICC line maintenance and care. During interview conducted on March 14, 2024 at approximately 4:00 PM, the supervising RN (Employee #8) and the administrator (Employee #9) confirmed there was no documentation in the personnel files prior to 03/14/2024 which provided evidence that the above referenced RN"s had completed a competency demonstration for maintenance and care of PICC land/or CVC lines.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted February 23 through February 25, 2021, Associated Family Home Care, Inc. was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced, onsite Medicare recertification survey conducted February 23 through February 25, 2021, Associated Family Home Care, Inc. was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the administrator, the agency failed to ensure written notice of the agency's transfer and discharge policies were provided to four (4) of four (4) patients who were discharged from home health services. (Patients #1, #2, #3 and #4) Finding include: On February 25, 2021 at approximately 12:27 PM, review of the undated agency policy titled "Patient Rights and Responsibilities" revealed the following: l. To be informed of the Agency's policies for Transfer and Discharge... On February 25, 2021 at approximately 12:28 PM, review of the undated agency policy titled "Discharge, Transfer and Referral Policy" revealed the following on page 2: Discharge planning will begin when you are admitted to the agency... On February 23, 2021 at approximately 10:45 AM, review of the agency admission folder failed to reveal that the patient rights notification forms had included the discharged and transfer policies/procedures included in the undated agency policy titled "Discharge, Transfer and Referral Policy". Patient #1: On February 23, 2021 at approximately 1:29 PM, review of the clinical record revealed the start of care date was 09/08/2020, the primary diagnosis was stage 2 pressure ulcer (open wound) of the sacral region (area at the base of the spine) and that SN services were to be provided for ten (10) weeks as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 09/08/2020 through 11/06/2020. Review of "Physician Order" documentation dated 09/11/2020 revealed home health aide (HHA) services were to be provided for a period of eight (8) weeks. On February 23, 2021 at approximately 12:20 PM, review of the "Employee Incident Report" dated 09/23/2020 revealed the attending physician was notified of the patient's discharge from the agency as a result of an incident involving a family member of the patient and a HHA (employee #8) which occurred on 09/21/2020. There was no documentation in the clinical record which provided evidence that the patient was provided with written notification of the agency's "Discharge, Transfer and Referral Policy". Patient #2: On February 23, 2021 at approximately 2:11 PM, review of the clinical record revealed the start of care date was 09/06/2020, the primary diagnosis was aftercare following joint replacement surgery and that SN services were to be provided for nine (9) weeks as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 09/06/2020 through 11/04/2020. Review of occupational therapy (OT) assessment/physician order documentation dated 09/07/2020 and 10/02/2020 revealed OT services were to be provided for a total of eight (8) weeks. Review of "Physician Order" documentation dated 09/30/2020 revealed the attending physician requested that the patient be discharged from the agency. There was no documentation in the clinical record which provided evidence that the patient was provided with written notification of the agency's "Discharge, Transfer and Referral Policy". Patient #3: On February 24, 2021 at approximately 12:36 PM, review of the clinical record revealed the start of care date was 10/30/2020, the primary diagnosis was age-related osteoporosis and that physical therapy (PT) services were to be provided one (1) time a week for one (1) week, followed by two (2) times a week for four (4) weeks, for a total of nine (9) PT visits, as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 10/30/2020 through 12/28/2020. Review of PT visit note documentation revealed a total of eight (8) PT visit were performed between 10/30/2020 and 11/24/2020. Review of "Physician Order" documentation dated 11/24/2020 revealed the patient be discharged from the agency due to all goals being met. There was no documentation in the clinical record which provided evidence that the patient was provided with written notification of the agency's "Discharge, Transfer and Referral Policy". Patient #4: On February 24, 2021 at approximately 12:59 PM, review of the clinical record revealed the start of care date was 01/08/2021, the primary diagnosis was Type 2 diabetes mellitus (diabetes) with foot ulcer (wound) and that an OT evaluation was to be performed as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/08/2021 through 03/08/2021. Review of OT assessment/physician order documentation dated 01/11/2021 revealed OT services were to be provided for a total of four (4) weeks. Review of "Physician Order" documentation dated 02/03/20201 revealed the patient be discharged from the agency due to all goals being met. There was no documentation in the clinical record which provided evidence that the patient was provided with written notification of the agency's "Discharge, Transfer and Referral Policy". During interview on February 25, 2021 at approximately 4:05 PM, the administrator confirmed there was no documentation in the clinical record which provided evidence that the above identified patients had received written notification of the agency's "Discharge, Transfer and Referral Policy".

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on review of agency policies/procedures, documentation and clinical records, and based on interview with the administrator, the agency failed to ensure written notification of the right to be free from verbal, mental, sexual, and physical abuse including injuries of an unknown source, neglect, and misappropriation of property was provided to four (4) of four (4) patients for whom a home visit was conducted and for whom home health services were provided for more than four (4) days. (Patients #5, #6, #8 and #9) Finding include: On February 25, 2021 at approximately 12:27 PM, review of the undated agency policy titled "Patient Rights and Responsibilities" revealed the following: 1. The statement of rights shall state at a minimum the patient has a right to...(g) Be free from verbal, mental, sexual, and physical abuse including injuries of an unknown source, neglect, and misappropriation of property... On February 23, 2021 at approximately 10:45 AM, review of the agency admission folder failed to reveal that the patient rights notification forms had included notification of the right to be free from verbal, mental, sexual, and physical abuse including injuries of an unknown source, neglect, and misappropriation of property. Patient #5: On February 24, 2021 at approximately 1:30 PM, review of the clinical record revealed the start of care date was 03/04/2020, the primary diagnosis was chronic tubulo-interstitial nephritis (inflammatory disease of the kidneys) and that skilled nursing (SN) services were to be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of 12/29/2020 through 02/26/2021. During a home visit conducted on February 24, 2021 at approximately 9:15 AM, review of the agency's admission folder revealed there was no documentation on the patient rights/consent forms which provided evidence that patient received written notification of the right to be free from verbal, mental, sexual, and physical abuse including injuries of an unknown source, neglect, and misappropriation of property. Patient #6: On February 24, 2021 at approximately 1:56 PM, review of the clinical record revealed the start of care date was 09/06/2019, the primary diagnosis was encounter for attention to cystostomy (surgically created opening into the bladder) and that SN services were to be provided as documented on the "Home Health Certification and Plan of Care" for the recertification period of 12/29/2020 through 02/26/2021. During a home visit conducted on February 24, 2021 at approximately 10:05 AM, review of the agency's admission folder revealed there was no documentation on the patient rights/consent forms which provided evidence that patient received written notification of the right to be free from verbal, mental, sexual, and physical abuse including injuries of an unknown source, neglect, and misappropriation of property. Patient #8: Between February 24, 2021 at approximately 2:18 PM and February 25, 2021 at approximately 7:02 AM, review of the clinical record revealed the start of care date was 01/30/2021, the primary diagnosis was encephalopathy (disease of the brain) and that SN, home health aide, physical therapy (PT), occupational therapy (OT) and speech therapy services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 01/30/2021 through 03/30/2021. During a home visit conducted on February 25, 2021 at approximately 9:45 AM, review of the agency's admission folder revealed there was no documentation on the patient rights/consent forms which provided evidence that patient received written notification of the right to be free from verbal, mental, sexual, and physical abuse including injuries of an unknown source, neglect, and misappropriation of property. Patient #9: On February 25, 2021 at approximately 7:29 AM, review of the clinical record revealed the start of care date was 02/12/2021, the primary diagnosis was type 1 diabetes mellitus (diabetes) with foot ulcer and that SN, PT and OT services were to be provided as documented on the "Home Health Certification and Plan of Care" for the initial certification period of 02/12/2021 through 04/12/2021. During a home visit conducted on February 25, 2021 at approximately 11:03 AM, review of the agency's admission folder revealed there was no documentation on the patient rights/consent forms which provided evidence that patient received written notification of the right to be free from verbal, mental, sexual, and physical abuse including injuries of an unknown source, neglect, and misappropriation of property. During interview on February 25, 2021 at approximately 4:05 PM, the administrator confirmed there was no documentation in the clinical record which provided evidence that the above identified patients had received written notification of the patient's right to be free from verbal, mental, sexual, and physical abuse including injuries of an unknown source, neglect, and misappropriation of property.