Every finding on record at Bonny Crest Home Healthcare, Inc

The Oklahoma State Department of health conducted a Medicare Emergency Preparedness Survey on 01/05/22. Deficiencies were cited as a result of the Emergency Preparedness survey.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development of an Emergency Preparedness Plan and program for all agency employees and patients. A request for agency Emergency Preparedness Program records and documentation yielded no results. An additional request for administrative records regarding emergency preparedness yielded no records for an emergency preparedness program for calendar years 2019, 2020 or 2021. On 01/05/22 at 11:11 am, Staff Z stated the agency had no Emergency Preparedness Program, records or documentation.

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), §485.625(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 record review and interview, the agency failed to ensure development, review and maintenance of an emergency preparedness plan based on a facility and community-based assessment and utilizing an all-hazards approach for all patients and agency staff. A request for agency Emergency Preparedness Program records and documentation yielded no results. An additional request for administrative records regarding emergency prepared yielded no records. On 01/05/22 at 11:11 am, Staff Z stated the agency had no Emergency Preparedness Program, records or documentation.

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), §485.625(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, 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 record review and interview, the agency failed to ensure emergency plan testing and participation in community based or facility based exercises for all agency patients and staff. A request for agency Emergency Preparedness Program records and documentation yielded no results. An additional request for administrative records regarding emergency preparedness yielded no records for calendar years 2019, 2020 or 2021. On 01/05/22 at 11:11 am, Staff Z stated the agency had no Emergency Preparedness Program, records or documentation.

The Oklahoma State Department of Health conducted an unannounced Medicare recertification survey at the agency on 01/05/22. An entrance conference was conducted with Staff Z. The survey process was explained. Questions were answered. Staff Z was identified as the contact person for administrative and clinical issues. Findings were discussed during an informal exit conference with Staff Z. The following condition level deficiencies were cited as a result of the recertification survey: 484.50 Patient Rights 484.65 QAPI 484.70 Infection prevention and control 484.105 Organization and administration of services 484.110 Clinical records 184.115 Personnel Qualifications

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the existence of and/or documentation of contact information given to patients for the purpose of making complaints with the agency for all patients and caregivers. This failed practice had the potential to stall the intake process and make it difficult for patients to initiate the complaint process for all patients and caregivers unfamiliar with making complaints to a home care agency. See G414. Based on record review and interview, the agency failed to ensure a system for complaint intake and investigation was developed and or documented for all patients, caregivers and staff. This failed practice had the potential to dissuade patients or staff from making a complaint with the agency and prevent the agency from acknowledging and investigating the occurrence of a complaint, allegations, issues from parties inside and outside of the agency. See G432. Based on record review and interview, the agency failed to ensure the existence of records were kept and/or available to show clients were advised of payment expectations and charges for services not covered by Medicare, Medicaid or other federally-funded programs for all patients currently on services. This failed process had the potential to impede or interrupt services if changes in payment sources occurred during the service period for all patients. See G440.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the existence of and/or documentation of contact information given to patients for the purpose of making complaints with the agency for all patients and caregivers. This failed practice had the potential to stall the intake process and make it difficult for patients to initiate the complaint process for all patients and caregivers unfamiliar with making complaints to a home care agency. A request for complaint record yielded to results. A request for patient records yielded no results. A request for policies and procedures yielded no results. A request for a start of care packet yielded no results. On 01/05/22 at 11:20 am, Staff Z stated: 1. The agency had no complaint records and had received no complaints; 2. The agency had no complaint policies and procedures; 3. The agency had no patient or administrative records available for surveyor review at this time; 4. The agency had no start of care packet for surveyor review; 5. The agency had no Medicare patients for the last two and a half years, 7. The records for Medicare patients were in the attic and could not be accessed at present; 8. The records for Medicare patients could not be accessed because they no longer had access to the EMR program.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure development or maintenance of a complaint program and agency efforts for all patient/caregivers to make complaints to the agency regarding concerns, care or lack thereof. This failed practice had the potential to delay, thwart or hamper the intake, investigation and resoution of complaints for all agency patients and staff with concerns and issues regarding care and treatment. A request for complaint record yielded to results. A request for patient records yielded no results. A request for policies and procedures yielded no results. A request for a start of care packet (to access information provided to patients) yielded no results. On 01/05/22 at 11:20 am, Staff Z stated: 1. The agency had no complaint records and had received no complaints; 2. The agency had no complaint policies and procedures; 3. The agency had no patient or administrative records available for surveyor review at this time; 4. The agency had no start of care packet for surveyor review; 5. The agency had no Medicare patients for the last two and a half years, 7. The records for Medicare patients were in the attic and could not be accessed at present; 8. The records for Medicare patients could not be accessed because they no longer had access to the EMR program

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the existence of records were kept and/or available to show clients were advised of payment expectations and charges for services not covered by Medicare, Medicaid or other federally-funded programs for all patients currently on services. This failed process had the potential to impede or interrupt services if changes in payment sources occurred during the service period for all patients. A request for patient records yielded no results. A request for policies and procedures yielded no results. A request for a start of care packet (to access information provided to patients) yielded no results. On 01/05/22 at 11:20 am, Staff Z stated: 1. The agency had no patient or administrative records available for surveyor review at this time; 2. The agency had no start of care packet for surveyor review; 3. The agency had no Medicare patients for the last two and a half years, 4. The records for Medicare patients were in the attic and could not be accessed at present; 5. The records for Medicare and Medicaid patients could not be accessed because they no longer had access to the EMR program.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure (and or document) patients were advised of the state toll free home helath telephone hotline or its purpose to receive complaints or questions for all patients on service.This failed practice had the potential to stave off the access of information or additional source to make a complaint for all patients and caregives. A request for QAPI and PIP records yielded no results. On 01/05/22 at 11:23, Staff Z stated the agency had no QAPI program, no PIPs, no policies and procedures, no governing body minutes, and no administrative records for review.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure development of a QAPI Program with efforts for improvement in indicators to improve health, patient safety and quality of care for all patients and agency staff. This failed practice had the potential to staunch self identified agency problems and immediate correction upon identification for all agency patients and staff. See G642. Based on record review and interview, the agency failed to ensure development and utilization of a QAPI program using OASIS and quality indicator data for self identification and correction of agency problems for all patients and agency staff. This failed practice had the potential to allow unresolved agency problems to continue and intensify with no avenue for corrective action for all agency staff and patients. See G644. Based on record review and interview, the agency failed to ensure development and maintenance of a QAPI program that focused on performance improvement activities for all staff and patients. This failed practice had the potential for missed opportunities to identify and correct or re-evaluation and implement additional interventions to correct know problems for the agency, their staff and patients. See G648. Based on record review and interview, the agency failed to ensure conduction of at least one PIP during the calendar years of 2019, 2020 and 2021 for all agency staff and patients. This failed practice had the potential to lead to a continuation of known problem areas with no avenue for correction and the potential for agency, patient or staff harm. See G458 Based on record review and interview, the agency's governing body failed to ensure: 1. development and implementation of an ongoing QAPI program: 2. QAPI efforts addressed priorities form improvement in patient care and safety; 3. all improvement efforts were evaluated for effectiveness; 4. expectations for patient safety were developed, implemented and continued; 5. findings of fraud or waste were identified and efforts made to correct. This failed practice had the potential for agency stagnation in self identification and corrective actions for all agency personnel, clients and caregivers. See G660

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development of a QAPI Program with efforts for improvement in indicators to improve health, patient safety and quality of care for all patients and agency staff. This failed practice had the potential to staunch self identified agency problems and immediate correction upon identification for all agency patients and staff. See G642. A request for QAPI and PIP records yielded no results. On 01/05/22 at 11:23, Staff Z stated the agency had no QAPI program, no PIPs, no policies and procedures, no governing body minutes, and no administrative records for review.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development and utilizetion of a QAPI program using OASIS and quality indicator data for self identification and correction of agency problems for all patients and agency staff. This failed practice had the potential to allow unresolved agency problems to continue and intensify with no avenue for corrective action for all agency staff and patients. A request for QAPI and PIP records yielded no results. On 01/05/22 at 11:23, Staff Z stated the agency had no QAPI program, no PIPs, no policies and procedures, no governing body minutes, and no administrative records for review.

High risk, high volume, or problem-prone area CFR(s): 484.65(c)(1)(i) (i) Focus on high risk, high volume, or problem-prone areas; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure development and maintenance of a QAPI program that focused on performance improvement activities for all staff and patients. This failed practice had the potential for missed opportunities to identify and correct or re-evaluation and implement additional interventions to correct know problems for the agency, their staff and patients. A request for QAPI and PIP records yielded no results. On 01/05/22 at 11:23, Staff Z stated the agency had no QAPI program, no PIPs, no policies and procedures, no governing body minutes, and no administrative records for review.

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure conduction of at least one PIP during the calendar years of 2019, 2020 and 2021 for all agency staff and patients. This failed practice had the potential to lead to a continuation of known problem areas with no avenue for correction and the potential for agency, patient or staff harm. A request for QAPI and PIP records yielded no results. On 01/05/22 at 11:23, Staff Z stated the agency had no QAPI program, no PIPs, no policies and procedures, no governing body minutes, and no administrative records for review.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency's governing body failed to ensure: 1. development and implementation of an ongoing QAPI program: 2. QAPI efforts addressed priorities form improvement in patient care and safety; 3. all improvement efforts were evaluated for effectiveness; 4. expectations for patient safety were developed, implemented and continued; 5. findings of fraud or waste were identified and efforts made to correct. This failed practice had the potential for agency stagnation in self identification and corrective actions for all agency personnel, clients and caregivers. See G660 A request for QAPI and PIP records yielded no results. On 01/05/22 at 11:23, Staff Z stated the agency had no QAPI program, no PIPs, no policies and procedures, no governing body minutes, and no administrative records for review.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure development and implementation of an infection control program, policies, procedures and standard precautions to prevent transmission of infections for all patients and staff. This failed process had the potential to contribute to cross contamination and transmission of infection to all staff, patients and caregivers. See G682 Based on record review and interview, the agency failed o ensure: 1. Development and maintenance of a coordinated agency-wide infection control program for identification, prevention, control and investigation of infections and communicable diseases and 2. The infection control program was an integral part of an agency QAPI program for all patients and staff. This failed practice had the potential to negatively impact patient, caregiver and staff health/wellbeing and safety during a time of crisis and pandemic. See G684 Based on record review and interview, the agency failed to ensure infection control education was provided and documented for all agency staff, patients, and caregivers. This failed practice left the agency vulnerable for potential complaints, cross-contamination of infection and blame for poor patient care practices by all agency staff, patients and caregivers. See G686.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure development and implementation of an infection control program, policies, procedures and standard precautions to prevent transmission of infections for all patients and staff. This failed process had the potential to contribute to cross contamination and transmission of infection to all staff, patients and caregivers. A request for infection control program records and policies and procedures yielded no results. On 01/05/22 at 11:23 am, Staff Z stated the agency had no infection control program or policies and procedures.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed o ensure: 1. Development and maintenance of a coordinated agency-wide infection control program for identification, prevention, control and investigation of infections and communicable diseases and 2. The infection control program was an integral part of an agency QAPI program for all patients and staff. This failed practice had the potential to negatively impact patient, caregiver and staff health/wellbeing and safety during a time of crisis and pandemic. See G684 On 01/05/22 at 11:23 am, Staff Z stated the agency had no infection control program, no staff training records and no policies and procedures.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure infection control education was provided and documented for all agency staff, patients, and caregivers. This failed practice left the agency vulnerable for potential complaints, cross-contamination of infection and blame for poor patient care practices by all agency staff, patients and caregivers A request for infection control program records, training records and policies and procedures yielded no results. On 01/05/22 at 11:23 am, Staff Z stated the agency had no infection control program, training records or policies and procedures.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure the governing body maintained and/or documented responsibility for the agency's overall management and operation to include fiscal operations, review of the agency's budget, operational plans and the QAPI program for all agency staff and patients. This failed practice had the potential to lead to poor agency practices such as failed processes, failure to identify agency needs, failure in compliance with federal requirements, lack of needed documentation and failure to identify needs, potentially affecting the agency, it's staff and all patients.. See G942). Based on record review and interview, the agency failed to ensure agency documentation of qualified personnel and the development and documentation of personnel qualifications, policies and procedures for all agency personnel. This failed process had the potential to lead to unqualified staff providing care to patients as well as a lack of checks and balances to ensure qualification. See G952. Based on record review and interview, the agency failed to ensure their services included skilled nursing services and at least one other therapeutic service for all patients who may be referred to the agency. This failed practice had the potential to lead to inability to provide needed services to patients referred to the agency and/or a delay in service due to the agency's need to refer elsewhere. See G982. Based on record review and interview, the agency failed to ensure the governing body maintained documentation of agency overall plan, budget, and capital expenditure plan. This failed practice had the potential to promote non-compliance with federal compliance by failing to have documentation readily available to needed administrative officers. See G988

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the governing body maintained and/or documented responsibility for the agency's overall management and operation to include fiscal operations, review of the agency's budget, operational plans and the QAPI program for all agency staff and patients. This failed practice had the potential to lead to poor agency practices such as failed processes, failure to identify agency needs, failure in compliance with federal requirements, lack of needed documentation and failure to identify needs, potentially affecting the agency, it's staff and all patients.. See G942). A request for governing body, administrative and QAPI records yielded no results. On 01/05/21 at 11:20 am, Staff Z stated they had no governing body records, administrative records or QAPI records.

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 record review and interview, the agency failed to ensure agency documentation of qualified personnel and the development and documentation of personnel qualifications, policies and procedures for all agency personnel. This failed process had the potential to lead to unqualified staff providing care to patients as well as a lack of checks and balances to ensure qualification. On 01/05/22 at 11:20 am, Staff G stated they had no staff records available for review and no verification of training or qualifications.

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: Based on record review and interview, the agency failed to ensure their services included skilled nursing services and at least one other therapeutic service for all patients who may be referred to the agency. This failed practice had the potential to lead to inability to provide needed services to patients referred to the agency and/or a delay in service due to the agency's need to refer elsewhere. On 01/05/21 at 11:11 am, Staff Z stated: 1. The agency provided no skilled services; 2. The agency had not had a Medicare patient for 2.5 years; 3. Whenever they received a Medicare patient they referred them to a different agency; 4. They were not recruiting Medicare patients; 5. They didn't provided skilled nursing, therapy, social work or aide services. 6. They wanted to maintain their CCN number in case they wanted to provide skilled services in the future.

Institutional planning CFR(s): 484.105(h) Standard: Institutional planning. The HHA, under the direction of the governing body, prepares an overall plan and a budget that includes an annual operating budget and capital expenditure plan. (1) Annual operating budget. There is an annual operating budget that includes all anticipated income and expenses related to items that would, under generally accepted accounting principles, be considered income and expense items. However, it is not required that there be prepared, in connection with any budget, an item by item identification of the components of each type of anticipated income or expense. (2) Capital expenditure plan. (i) There is a capital expenditure plan for at least a 3-year period, including the operating budget year. The plan includes and identifies in detail the anticipated sources of financing for, and the objectives of, each anticipated expenditure of more than $600,000 for items that would under generally accepted accounting principles, be considered capital items. In determining if a single capital expenditure exceeds $600,000, the cost of studies, surveys, designs, plans, working drawings, specifications, and other activities essential to the acquisition, improvement, modernization, expansion, or replacement of land, plant, building, and equipment are included. Expenditures directly or indirectly related to capital expenditures, such as grading, paving, broker commissions, taxes assessed during the construction period, and costs involved in demolishing or razing structures on land are also included. Transactions that are separated in time, but are components of an overall plan or patient care objective, are viewed in their entirety without regard to their timing. Other costs related to capital expenditures include title fees, permit and license fees, broker commissions, architect, legal, accounting, and appraisal fees; interest, finance, or carrying charges on bonds, notes and other costs incurred for borrowing funds. (ii) If the anticipated source of financing is, in any part, the anticipated payment from title V (Maternal and Child Health Services Block Grant) or title XVIII (Medicare) or title XIX (Medicaid) of the Social Security Act, the plan specifies the following: (A) Whether the proposed capital expenditure is required to conform, or is likely to be required to conform, to current standards, criteria, or plans developed in accordance with the Public Health Service Act or the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963. (B) Whether a capital expenditure proposal has been submitted to the designated planning agency for approval in accordance with section 1122 of the Act (42 U.S.C. 1320a-1) and implementing regulations. (C) Whether the designated planning agency has approved or disapproved the proposed capital expenditure if it was presented to that agency. (3) Preparation of plan and budget. The overall plan and budget is prepared under the direction of the governing body of the HHA by a committee consisting of representatives of the governing body, the administrative staff, and the medical staff (if any) of the HHA. (4) Annual review of plan and budget. The overall plan and budget is reviewed and updated at least annually by the committee referred to in paragraph (i)(3) of this section under the direction of the governing body of the HHA. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure the governing body maintained documentation of agency overall plan, budget, and capital expenditure plan. This failed practice had the potential to promote non-compliance with federal compliance by failing to have documentation readily available to needed administrative officers. On 01/05/21 at 11:20 am, Staff Z stated they had no governing body or administrative records.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure maintenance and availability of clinical records for an unknown number of patients on service with the agency during calendar years 2019, 2019, and 2021. This failed practice had the potential for a delay in assessment and clinical information on patient request (for an unknown amount of clients) as well as an inability to complete record review during recertification, licensure or complaint surveys when required See G1012 Based on record review and interview, the agency failed to ensure contact information for patients, patient's representatives and patient's primary caregivers were available in the clinical record for all patients on service during calendar years 2018, 2019 and 2021. This failed practice had the potential for an incomplete Medicare recertification survey as well as a delay in patient contact information if requested by an authorized agency or representative. See G1018 Based on record review and interview, the agency failed to ensure documentation of patient discharge and transfer was available in clinical records at surveyor request for an unknown number of patients on service with the agency during calendar years 2018, 2019, and 2021. This failed practice had the potential to thwart survey efforts during a required Medicare recertification survey. See G1022

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure maintenance and availability of clinical records for an unknown number of patients on service with the agency during calendar years 2019, 2019, and 2021. This failed practice had the potential for a delay in assessment and clinical information on patient request (for an unknown amount of clients) as well as an inability to complete record review during recertification, licensure or complaint surveys when required. On 01/05/22 at 11:11 am, Staff Z stated they had no available clinical records for review for current patients or patients on service during calendar years 2018, 2019, 2020, and 2021.

Contact information for the patient CFR(s): 484.110(a)(4) Contact information for the patient, the patient's representative (if any), and the patient's primary caregiver(s); This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure contact information for patients, patient's representatives and patient's primary caregivers were available in the clinical record for all patients on service during calendar years 2018, 2019 and 2021. This failed practice had the potential for an incomplete Medicare recertification survey as well as a delay in patient contact information if requested by an authorized agency or representative. On 01/05/22 at 11:11 am, Staff Z stated they had no clinical records available for review for current patients or for patients on service during calendar years 2018, 2019, 2020 or 2021.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure documentation of patient discharge and transfer was available in clinical records at surveyor request for an unknown number of patients on service with the agency during calendar years 2018, 2019, and 2021. This failed practice had the potential to thwart survey efforts during a required Medicare recertification survey. On 01/05/22 at 11:11 am, Staff Z stated they had no records available for review for current patients or patients on service with the agency during calendar years 2018, 2019, 2020 or 2021.