Every finding on record at Atlas Healthcare Management, Inc

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), §485.625(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: A. Based on review of the Agency’s Emergency Preparedness Plan, Agency policy and staff interview, it was determined the Agency failed to ensure the Emergency Plan included volunteers. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency’s Emergency Preparedness Plan last revised on 5/15/21 was reviewed on 11/29/21 at 11:30 AM. The Plan lacked any documentation relative to the use of volunteers. 2. The Emergency Preparedness Plan Policy was reviewed on 11/29/21 at 11:30 AM and included under Volunteer: “The administrator of Agency shall appoint a volunteer to play a role for integration of State or Federally designated health care professionals to address surge needs during an emergency.” 3. During an interview with the Agency Supervisor on 11/29/21 at 2:30 PM, the Agency Supervisor confirmed the Agency failed to incorporate volunteers to the Agency’s Emergency Preparedness Plan.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: A. Based on review of the Agency's Emergency Preparedness Plan, Agency policy and staff interview, it was determined the Agency failed to ensure the communication plan was complete. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency's Emergency Preparedness plan last revised 5/15/21 was reviewed on 11/29/21 at 11::30 AM. The telephone Staff Phone Tree, Emergency Contacts and Vendors lacked the information needed; they were left blank. 2. The Emergency Preparedness Plan Policy was reviewed on 11/29/21 at 11:30 AM and included: “Agency shall develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws….” The communication plan includes all the following: 1. Names and contact information for the following: i. Staff. ii. Entities providing services under arrangement. iii. Patient’s physicians. iv. Volunteers. 2. Contact information for the following: i. Federal, State, tribal, regional, or local emergency preparedness staff. ii. Other sources of assistance. 3. During an interview with the Agency Supervisor on 11/29/21 at 2:30 PM, the Agency Supervisor confirmed the Agency failed to include the above information in the Agency's Emergency Preparedness communication plan.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: - = to # = number AM = morning Obs = observed TB = tuberculosis PM = afternoon/evening Pt./ Pts. = Patient/Patients HHA = Home Health Agency CMS = Centers for Medicare and Medicaid Services

Documentation of competency evaluation CFR(s): 484.80(c)(5) The HHA must maintain documentation which demonstrates that the requirements of this standard have been met. This ELEMENT is not met as evidenced by: A. Based on review of a personnel file, Agency policy and staff interview, it was determined the Agency failed to complete and maintain a competency evaluation for the Home Health Aide. This was found in 1 of 1 (Employee #3) Home Health Aide personnel file reviewed. Findings include: 1. The personnel file of Employee #3 was reviewed on 11/29/21 at 12:20 PM. The file lacked documentation the Agency conducted a written and/or observed skills competency of the Home Health Aide, prior to Employee #3 providing service. 2. The Agency's policy titled, "Employee Competency" was reviewed on 11/29/21 at 1:20 PM and contained: "All employees of the Agency will ensure that all employees have demonstrated competence to perform their duties...3. Competency assessment is based on the service provided and the staff members' role and job responsibilities and shall include methods such as clinical observation, skills lab review, supervisory visits, knowledge-based tests, situational analysis/case studies... 4. Competency is established during the initial hiring period and orientation..." 3. During an interview with the Agency Supervisor on 11/29/21 at 3:25 PM, the Agency Supervisor confirmed the Agency lacked documentation the Home Health Aide completed a competency evaluation upon hire.

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: A. Based on a review of personnel files, Agency policy and staff interview, it was determined the Agency failed to ensure hiring practices were followed. This was found in 1 of 2 (Employee #2) direct staff that provide Pt. care. Findings include: 1. The personnel file of Employee #2 was reviewed on 11/29/21 at 12:20 PM. The file included the forms "Health Statement, Employee Health Record and TB Targeted Medical Questionnaire Form" that were all completed by Employee #2. The personnel file/Agency lacked any documentation that a Physician or Nurse Practitioner conducted the health screening at the time of hire. 2. The Agency policy titled, "Employee Health" was reviewed on 11/29/21 at 12:50 PM and contained: "...Physical exam 1. All new employees providing direct patient care will be required to have proof of a physical examination within the past 180 days prior to patient contact by a physician or nurse practitioner...Tuberculosis 1. At the time of hire... a. Any person with a negative history of TB must have a baseline two-step tuberculin skin test using the Mantoux method or a quantiferon-TB assay unless there is documentation that a TB skin test has been applied during the past 12 months with a negative result..." 3. During an interview with the Agency Supervisor on 11/29/21 at 3:25 PM, the Agency Supervisor confirmed the above findings.

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: A. Based on a review of the designation letter for the Administrator, Agency policy and staff interview, it was determined the Agency failed to maintain documentation the Designated Alternate for the Administrator meet the qualifications. This has the potential to affect all services provided by the Agency. Findings include: 1. The document titled "Job Description Alternate Administrator" was reviewed on 11/29/21 at 2:20 PM. The document indicated that Employee #4 assumed this position and was approved by the Governing Body on 6/17/21. A request was made to review the personnel file and/or documentation indicating Employee #4 had the experience and eligible to assume the role of the Alternate Administrator, also had received orientation to the duties and responsibilities of this role. As of 11/2921 at 4:15 PM, the Agency was unable to provide any of the requested documentation. 2. The Agency policy titled, "Alternate Administrator" was reviewed on 11/29/21 at 2:45 PM. The policy required: "...1. The candidate for Alternate Administrator shall meet the same qualifications as the Administrator... 4. Upon approval, the Alternate Administrator will be hired and orientated to the Agency's Policies and Procedures and job description." 3. During an interview with the Agency Supervisor on 11/29/21 at 3:25 PM, the Agency Supervisor confirmed the above findings.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: A. Based on staff interview, review of an unduplicated Pt. Survey report, CMS Outcome Report and the CMS-1572(a)(b) form, it was determined the Agency failed to provide any services intermittently at a patient's residence for the past year. This has the potential to affect the Agency's organizational and administrative abilities. Findings include: 1. Upon entering the Agency on 11/29/21 at 9:15 AM, an interview was conducted with the Administrator and Agency Supervisor that stated, the Agency had not provided any services since 2020. 2. On 11/29/21 at 10:00 AM, the Agency Supervisor presented the "Patient Survey Census" report which included written documentation that service was last provided to a Pt. on 10/1/20. At 10:21 AM, the Agency Supervisor presented a second report which included the names of 4 Pts. in which service ended for 2 Pts. on 10/1/21 and 2 Pts. on 10/3/21. 3. The CMS Outcome Report was reviewed on 11/29/21 at 7:50 AM and contained documentation that for "01/2019 - 12/2020" the Agency had "5 Obs Eligible Cases Discharge to Community". No other reports were available. 4. The report titled CMS 1572(a)(b) completed by the Administrator and presented on 11/29/21 at 1:50 PM included documentation the Agency had not provided any services within the past 12 months. 5. During an interview with the Agency Supervisor on 11/29/21 at 3:25 PM, the Agency Supervisor confirmed the Agency failed to provide any service within the past year.