Every finding on record at Capital Region Home Health Inc.

Emergency Preparedness Survey Abbreviation: EP- Emergency Preparedness

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interviews, the agency failed to develop and maintain an Emergency Preparedness (EP) Plan at least every 2 years which included a facility-based and community-based risk assessment. This deficient practice had the potential to affect all 156 patients, according to the agency’s current census. Findings: Review of the agency’s policy titled “Natural Disasters/Emergencies”, with a revision date of April 2018, revealed in part: Procedure: Additional or alternate guidelines should be included by the organization based on its hazard vulnerability analysis and subsequent plan. Review of the agency’s January 2024 EP Plan revealed there was no facility-based and community- based risk assessment included or available for review. An interview was conducted with S2DON on 03/14/2025 at 2:00 p.m. S2DON stated she did not know a risk assessment should be included with the agency’s EP Plan. S2DON confirmed the agency had not completed a facility-based and community-based risk assessment for the 2024 EP Plan and should have. An interview was conducted with S4DOO on 03/14/2025 at 2:50 p.m. S4DOO was made aware of the above missing risk assessment documentation. S4DOO stated the agency should be in compliance with all state laws and regulations and was not.

Recertification Survey Abbreviations: CMS- Centers for Medicare and Medicaid Services OASIS- Outcome and Assessment Information Set PoC- Plan of Care SoC- Start of Care

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 30 days of completion. Findings: Review of the agency’s policy titled, “OASIS Data Transmission”, with a revision date of April 2018, revealed in part:Purpose: To outline the OASIS data transmission requirements.Policy: The organization will adhere to all OASIS data transmission requirements as outlined in the Medicare Conditions of Participation, Reporting of OASIS Information.Procedure:1. The organization will encode and transmit completed OASIS data for each applicable patient within thirty days of the M0090 date, date assessment completed.Review of the agency's OASIS Agency Final Validation Report with a submission date of 01/28/2025 revealed 22 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 02/03/2025 revealed 38 records were processed with 1 record receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 02/06/2025 revealed 2 records were processed with 2 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with a submission date of 02/24/2025 revealed 56 records were processed with 3 records receiving a message the record was submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted with S2DON on 03/14/2025 at 2:00 p.m. S2DON confirmed the above records were submitted late. S2DON stated OASIS Assessments should have been submitted within 30 days of completion.

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the agency failed to have the Plan of Care (PoC) reviewed and revised by the physician every 60 days, beginning with the SOC (Start of Care) date for 2 (#7 and #16) of 17 (#1-#17) sampled patients reviewed. This deficient practice had the potential to affect all 156 patients, according to the agency’s current census. Findings: Review of the agency’s policy titled “Reassessments/Recertification” with a revision date of April 2018, revealed in part: Policy The comprehensive assessment must be updated and revised every 60 days beginning with the start of care. Procedure 12. The updated plan of care will be prepared and sent to the physician for review and signature in a timely manner. Patient #7 Review of Patient #7's Clinical Record revealed Patient #7's SOC date was 10/23/2024. Review of the PoC for certification period 10/23/2024 through 12/21/2024 revealed the physician did not sign the PoC until 03/14/2025. Patient #16 Review of Patient #16’s Clinical Record revealed Patient #16’s SOC date was 03/12/2024. Review of the PoC for certification period 03/12/2024 through 05/10/2024 revealed the physician did not sign the PoC until 07/08/2024. An interview was conducted with S2DON on 03/14/2025 at 2:00 p.m. The above PoC for Patient #7 and Patient #16 were reviewed. S2DON confirmed all PoC orders should be reviewed and signed by the physician within 60 days, and Patient #7 and Patient #16’s were not.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This ELEMENT is not met as evidenced by: Based on record reviews and interviews, the agency failed to ensure a Home Health Aide Supervisory Visit was conducted every fourteen days for 1 (#5) patient with Home Health Aide Services, out of a total sample of 17 patients reviewed. Findings: Review of the agency’s policy titled “Home Health Aide Supervisory Visits”, with a revision date of April 2018, revealed in part: Policy: The registered nurse or other appropriate skilled professional familiar with the patient, the patient’s plan of care, and written patient care instructions must conduct supervisory visits to the patient’s residence at regular intervals. Procedure: 1. The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days. Review of Patient #5’s Clinical Record revealed he began receiving services from the agency on 01/03/2025, with a prior certification period of 01/03/2025 through 03/03/2025, and a current certification period of 03/04/2025 through 05/02/2025. Review of Patient #5’s Physician Ordered discipline frequency revealed he received Home Health Aide visits two times a week for four weeks beginning 02/03/2025, then one time a week for nine weeks beginning 03/04/2025. Review of Patient #5’s Home Health Aide visit calendar revealed, in part, he had visits completed on 02/03/2025, 02/07/2025, 02/10/2025, 02/13/2025, 02/17/2025, 02/20/2025, 02/24/2025, 02/27/2025, 03/04/2025 and 03/13/2025. Review of Patient #5’s Nursing visit calendar revealed, in part, he had Nursing visits completed on 02/03/2025, 02/10/2025, 02/20/2025 and 03/05/2025 by S14LPN, and on 02/27/2025 by S6RN. Review of Patient #5’s Nursing Visit notes revealed a Home Health Aide Supervisory Visit was not conducted the week of 02/21/2025. Review of Patient #5’s Occupational Therapy (OT) visit calendar revealed, in part, he had OT visits completed on 02/07/2025, 02/27/2025, and 03/13/2025. Review of Patient #5’s Occupational Therapy Visit Notes revealed a Home Health Aide Supervisory Visit was conducted on 02/07/2025 by S11OT. Further review revealed a Home Health Aide Supervisory Visit was not conducted the week of 02/21/2025. A telephone interview was conducted with S14LPN on 03/14/2025 at 1:55 p.m. S14LPN stated she was assigned to see Patient #5 alternating with S6RN. S14LPN stated Patient #5 was seen by her on 02/20/2025. S14LPN stated S6RN and S11OT were not scheduled to see Patient #5 the week of 02/20/2025. S14LPN confirmed a Home Health Aide Supervisory Visit was not conducted every 14 days and should have been. A telephone interview was conducted with S11OT on 03/14/2025 at 2:03 p.m. S11OT reviewed Patient #5’s Clinical Record and confirmed a Home Health Aide Supervisory Visit was not conducted every 14 days and should have been. An interview was conducted with S2DON on 03/14/2025 at 2:08 p.m. S2DON stated a Home Health Aide Supervisory Visit should be conducted by either a Registered Nurse or OT every 14 days. S2DON reviewed Patient #5’s Clinical Record and confirmed a Home Health Aide Supervisory Visit was not conducted every 14 days and should have been.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey Complaint Survey #LA00062953. G0452 was cited for Compliant #LA00062953 ADL Activity of daily living HHA Home Health Aide MD Medical Doctor MSW Master Social Worker OT Occupational Therapist PT Physical Therapist SN Skilled Nurse wk week

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on interviews and record review, the agency failed to follow the Discharge Criteria and Process policy for 1 (#10) of 4 (#8, #9, #10 and #11) patients discharged from the agency. The agency failed to inform Patient #10 when services provided by the agency were being discontinued. Review of the agency policy titled” Discharge Criteria and Process” revealed the following: Purpose: To outline the process for discharging a patient from services. Policy: When the patient’s plan of care changes and this change results in discharge or reduction of services, the patient or his/her representative as well as his/her primary physician will be notified and involved in planning decisions. Procedure: 1. The organization will verbally notify the patient of the decision to terminate or reduce services within one visit prior to the time the change in service is to occur. 2. A copy of the discharge instructions will be mailed to the patient. 4. For a patient requiring continuing care, assistance will be given to the patient and family/caregiver in order to manage continuing care needs after the organization services are discontinued. Review of the clinical record for Patient #10 revealed the patient began receiving services with the agency on 03/01/2022. The patient had diagnoses that included Acute Kidney Failure, Muscle Weakness, Burn of Second Degree of Scalp, Burn of Second Degree of Neck, Type II Diabetes Mellitus, Hypertensive Chronic Kidney Disease, Legal Blindness, and Major Depressive Disorder. Review of the current Plan of Care for Patient #10 revealed he was certified to receive services from 03/01/2022 to 04/29/2022. He received the following services: SN 2wk2, 1wk7 HHA: effective 03/06/2022; 1wk1, 2wk4, 1wk1 PT: effective 03/02/2022; 2wk4 OT: effective 03/04/2022; 1wk 2, 2wk5 Review of the coordination notes for Patient #10 revealed no documentation Patient #10 or his daughter/caregiver was informed of discontinuation of home health services. Further review revealed Patient #10 was not provided discharge instructions by mail or that assistance would be given to manage continued care needs as stated in the agency’s discharge policy. An interview was conducted on 04/27/2022 at 11:10 a.m. with S3RN. She said she provided care to Patient #10. She said Patient #10’s daughter only wanted home health aide services. She said Patient #10’s needs were discussed in the weekly patient case conference meeting on 04/13/2022 and it was decided that Patient #10 could not receive only HHA services without another discipline visiting in the home during the certification period. She said she texted Patient #10’s daughter and informed her that HHA services could not be provided without other disciplines involved in his care. She said she was unsure of the date she texted Patient #10’s daughter. She said she was unsure if Patient #10’s daughter received the text message. She said she was unsure if she informed Patient #10’s daughter that he would be discharged from the agency. She said she could not provide documentation indicating Patient #10’s daughter/caregiver was contacted regarding discontinued services. She confirmed she instructed the HHA to discontinue services to Patient #10. She said she did not verbally communicate the plan of discharge to the OT or the PT. An interview was conducted on 04/27/2022 at 1:30 p.m. with S1DON. She said on 04/13/2022 during the patient care conference meeting, she directed S3RN to verbally inform Patient #10 and his family that HHA services will no longer be conducted due to insurance reasons. She said S3RN was told to explain to Patient #10 and his daughter/caregiver that HHA services could no longer continue without a SN or OT providing services simultaneously. She said Patient #10’s daughter/caregiver refused visits from SN, OT and PT. She said the daughter/caregiver wanted HHA services only. She said there was lack of communication between the RN, OT, PT and the HHA. She said each discipline was responsible for communicating patient care issues. She said the disciplines were not communicating until it was discovered all discipline services had been discontinued except for the HHA. She said Patient #10 was discharged inappropriately and not according to the agency’s policy. She further confirmed Patient #10 and the daughter/caregiver should have been informed verbally of the decision to terminate services and a copy of the discharge instructions should have been mailed to the patient. She said these were not done, therefore the home health discharge for Patient #10 was not conducted according to the agency’s policy. She said she was responsible for ensuring discharge procedures were conducted appropriately for each patient.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on interviews and record review, the agency failed to communicate with the physician for 1(#7) of 11(#1-#11) patients reviewed. The agency failed to ensure the MSW contacted the physician when it was determined Patient #7 needed additional assistance with ADL’s in the home. Review of the clinical record for Patient #7 revealed the patient began receiving services with the agency on 03/25/2022. The patient had diagnoses that included Pressure Ulcer of Sacral Region Stage 2, Essential Hypertension, Emphysema, Type II Diabetes Mellitus, Old Myocardial Infarction, and History of Falling. Review of the current Plan of Care for Patient #7 revealed he was certified to receive services from 03/25/2022 – 05/23/2022. He received SN services 1wk1, 2wk8, 1wk1. Review of the SN coordination notes dated 03/28/2022 for Patient #7 revealed the following: Patient concern: May we please have an order for a social worker to evaluate patient for available community resources. Patient was living in sub-standard housing and possible unsafe living conditions. Review of the MSW assessment notes dated 03/30/2022 revealed the following concerns regarding Patient #7: Transportation- no current reliable transportation service. Provider – client cannot physically do laundry, client cannot physically perform housekeeping and client cannot consistently prepare meals. Physical – client unable to physically perform ADL’s. Social Support- limited family members/friends available or supportive Nutritional- client unable to prepare meals Financial- client does not have financial means to pay for health related care; medications, homemaker services. Community Resources- needed. Homebound status- needs assistance of another person in order to leave place of residence. Change of Service provided- no additional visits required outside current frequency. An interview was conducted on 04/26/2022 at 1:30 p.m. with S2MSW. She verified she visited Patient #7 on 03/30/2022 to assess his needs after being consulted by the nurse. She said when she visited Patient #7, she identified multiple areas of concerns regarding assistance with ADL’s. She said the patient acknowledged he was left alone most of the time and needed assistance with ADL’s. She said the patient was bedbound and could not perform ADL’s independently. She said the family assisted with care approximately 2 times per week. She said the patient was living in “basically a shed that was converted into a home.” She said she did not request for additional disciplines to assist with care because he was not eligible for additional services due to his present insurance company. She verified Patient #7 could benefit from additional assistance in the home. She confirmed she did not inform Patient #7’s doctor regarding his additional needs that she identified when she made the home visit on 03/30/2022. She said she did not follow up with assisting with additional care for Patient #7 because his insurance company only paid for one visit. An interview was conducted on 04/26/2022 at 1:50 p.m. with S1DON. She said a request was made for a MSW evaluation after the nursing staff identified multiple ADL concerns for Patient #7. She said the MSW should have contacted the home health agency and the doctor when she identified Patient #7’s need for assistance with ADL’s. She said the MD could have requested OT and HHA services to assist the patient with his ADL care. She said “just because he had a particular insurance company, does not mean he does not qualify for additional services.” She reviewed the MSW visit note dated 03/30/2022 and confirmed there were no specific plans to assist Patient #7 with his needs. She confirmed the MSW documented areas of concerns regarding Patient #7, but no documentation to indicate she provided assistance with additional services. She confirmed the MSW failed to communicate to the MD and the home health agency when she identified Patient #7 needed additional services with ADL’s.