Every finding on record at Care for Life Home Health, Inc.

Recertification survey conducted. Standard level deficiencies cited.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of the Emergency preparedness Plan and staff interview, it was determined that the Agency failed to provide emergency preparedness training to staff at least every two years. This has the potential to affect employees and patients served by the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 01/17/24 at 9:00 AM. The plan did lacked documentation indicating that the Agency conducted EP training since 2020. 2. During an interview with the Acting Administrator/DON on 01/17/24 at 11:00 AM, it was confirmed that the Agency failed to conduct EP training, since 2020.

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 review of the Emergency preparedness Plan and staff interview, it was determined that the Agency failed to participate in or conduct testing of the emergency preparedness plan since 2020. This has the potential to affect all employees and patients served by the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 01/17/24 at 9:00 AM. The plan lacked documentation indicating that the Agency conducted / participated in any testing exercises or drills since 2020. 2. During an interview with the Acting Administrator/DON on 01/17/24 at 11:00 AM, it was confirmed that the Agency failed to conduct / participate in a community and/or facility based exercise or drill since 2020.

Recertification survey conducted. Standard level deficiencies cited. Abbreviations: Pt./Pts. = patient/patients SN = Skilled Nurse POC = plan of care AM = morning PM = afternoon DON = Director of Nursing OT = Occupational Therapy PT = Physical Therapy

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of clinical records and staff interview, it was determined for 4 of 10 (Pts. # 1, 2, 7 and 8) clinical records reviewed, the Agency failed to ensure staff conformed with physician orders. Findings include: 1. Pt.#1 was admitted to Home Health Services on 11/25/23 with Diagnosis of Pressure Ulcer of Sacral region Stage 3. The clinical record was reviewed on 01/16/24 at 12:00 PM. The clinical record contained a POC dated 11/25/23, that required OT service 1 time a week for 4 weeks. The clinical record lacked the OT visits after 11/30/23 (week #1). 2. Pt.# 2 was admitted to Home Health Services on 01/12/24 with Diagnosis of Essential (Primary) Hypertension. The clinical record was reviewed on 01/16/24 at 3:30 PM. The clinical record contained a POC dated 01/12/24, that required an OT evaluation. During an interview with the Acting Administrator/DON on 01/17/24 at 3:30 PM, she stated she did not know when the OT evaluation was scheduled, but should have been conducted within 48 hours of referral. As of 01/16/24, the clinical record lacked the OT evaluation visit . 3. Pt.# 7 was admitted to Home Health Services on 12/14/23 with Diagnosis of Encounter for other orthopedic aftercare. The clinical record was reviewed on 01/16/24 at 3:00 PM. The clinical record contained a POC dated 12/14/23, that required OT service 1 time a week for 6 weeks. The clinical record lacked the OT visits after 12/29/23 (week #3). The POC also required, PT service 1 time a week for 1 week, 2 times a week for 2 weeks and 1 time a week for 4 weeks. The clinical record lacked the PT visits after 01/03/24 (week #4). 4. Pt.# 8 was admitted to Home Health Services on 10/28/23 with Diagnosis of Venous Insufficiency (Chronic Peripheral). The clinical record was reviewed on 01/17/24 at 9:30 AM. The clinical record contained a POC dated 10/28/23, that required SN service 1 time a week for 1 week and 2 times a week for 8 weeks. The clinical record lacked the second SN visits for the weeks of 11/29/23 (week #2) and 11/12/23 (week #4). 5. The above findings were confirmed with the Acting Administrator/ DON on 01/17/24 between 10:30 AM and 11:30 AM.

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 the review of clinical records and staff interview, it was determined the Agency failed to complete a discharge summary, and failed to ensure a copy of the transfer and/or discharge summary was sent to the Physician. This was found in 2 of 3 (Pts. #9 and 10) discharged clinical records reviewed. 2. Pt. #10 was admitted to Home Care services on 10/03/23 with diagnosis of Hypertensive heart disease with heart failure. Pt. # 10 was discharged from Agency on 01/04/24. The clinical record was reviewed 01/17/24. The certification period 12/05/23 to 01/04/24 included an Oasis non-visit note dated 01/04/24. The clinical record lacked evidence that the summary was sent to the physician or the accepting facility. The record included a visit note dated 12/28/23 completed by the Physical Therapist, the note included documentation that Pt #10 was approaching discharge likely from PT to Hospice. As of 1/17/24, the record lacked a discharge summary for PT. 3. During interview with the Acting Administrator/Director of Nursing, on 01/17/24 at 1:30 PM the above findings were confirmed. Findings include: 1. Pt. #9 was admitted to Home Health services on 12/18/23 with diagnosis of Cellulitis of Right Lower limb. The clinical record was reviewed on 01/17/24. The discharged date was 01/03/24. The discharge summary was dated 01/17/24 (14 days after the discharge). As of 01/17/24, the clinical record lacked evidence that the discharge summary was sent to the physician.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(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 LTC facilities at §483.73(a)(1):] 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)(1):] 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. * [For Hospices at §418.113(a)(2):] 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. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure it developed strategies for addressing emergency events identified by its Hazard Vulnerability Risk Assessment. Findings include: 1. The Agency's Emergency Preparedness plan was reviewed on 2/10/21 at 10:30 AM. The plan contained a Hazard Vulnerability Assessment, which the DON indicated was last updated in March of 2020. This assessment included the following emergency events were rated at a "3" (high probability of occurrence): Ice/Snow; Flooding; Tornado, and Pandemic/Infectious Disease. The plan lacked strategies for addressing these events, should they occur. 2. During an interview with the DON on 2/10/21 at 1:35 PM, the DON confirmed the above finding.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(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).] 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 review, and staff interview, it was determined the Agency failed to ensure its communication plan contained the names and contact information for its staff , entities providing services under arrangement, Pt. Physicians, and volunteers. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 2/10/21 at 10:30 AM. The Plan contained a "Staff Phone Tree" which contained the names and contact information for the Administrator, DON, and Administrative Assistant. This phone tree lacked the names and contact information of the Agency's Skilled Nurses, Home Health Aide, entities who provide services under arrangement (Physical, Occupational, and Speech Therapists, Medical Social Worker), Pt. Physicians, and volunteers. 2. The Agency policy titled "All-Hazard Emergency Policy" was reviewed on 2/10/21 at 10:50 AM. The policy required: "...Objective: To coordinate Agency staff members in Patient care and evaluation, as well as any Agency personnel assistance with care of those in the community who are affected by the emergency..." 3.. During an interview with the DON on 2/10/21 at 1:35 AM, the DON confirmed the above finding.

EP Testing Requirements CFR(s): 484.102(d)(2) *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, 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 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 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. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to conduct both a full-scale exercise/actual emergency and a tabletop exercise biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 2/10/21 at 10:30 AM. This plan contained documentation of an actual emergency related to the COVID-19 pandemic, which was dated 3/12/20. The plan lacked documentation of any additional full-scale or table top emergency preparedness exercises. 2. During an interview with the DON on 2/10/21 at 1:35 PM, the DON confirmed the above finding.

Recertification survey completed. Standard level deficiencies cited. A focused Infection Control Survey (FIC) was conducted on 2/11/21. Standard level deficiencies written. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of |Care E = Employee SN = Skilled Nurse RN = Registered Nurse DON = Director of Nursing MD = Medical Doctor POC/PsOC = Plan of Care/Plans of Care AM = Morning PM = Evening, night DON = Director of Nursing mg/MG = milligrams ml = milliliters Rt. = Right PICC = Peripherally Inserted Central Catheter O2 = Oxygen IV = Intravenous tab = tablet UA = Urinalysis UTI = Urinary Tract Infection po/PO = by mouth PPE = Personal Protective Equipment DME = Durable Medical Equipment COVID-19 = Coronavirus Disease 2019 CDC = Centers for Disease Control

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician may choose to include. This ELEMENT is not met as evidenced by: . A. Based on observation and interview during home visits, clinical record review and staff interview, it was determined the Agency failed to ensure the PoC contained supplies and/or equipment, and accurate medications. This was found in 3 of 7 (Pts. #1, 2 and 6) clinical records reviewed. Findings include: 1. Pt. #1. SOC 12/3/20. Diagnoses: Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Chronic Obstructive Pulmonary Disease with Acute Respiratory Infection and Unspecified Organism Pneumonia. A home visit was conducted on 2/8/21 at 1:30 PM with E #1. During the home visit, an observation was made that the Pt. was receiving Oxygen and the SN provided care to the right chest mediport. The Pt. stated he/she administer intravenous medications through the mediport several times a day. The clinical record was reviewed on 2/9/21 at 9:15 AM. The record contained the POC for the certification period of 12/3/20 to 1/31/21 and the POC effective 2/1/21 which included a section titled: "DME and Supplies" requiring the SN to enter the type of "DME and Supplies" the Pt. use, and "Name, Phone" of the DME company. The PsOC lacked the name of the company that provided the Oxygen, supplies for the right chest mediport, intravenous medications and intravenous supplies. The PsOC effective 12/3/20 and 2/1/21 included: "...SN to instruct patient/caregiver ... administer O2 at 3 liters per minute via nasal cannula..." During the home visit on 2/8/21, an interview was conducted with the Pt. that stated, O2 is administered 24 hours per day, 3 liters at rest, 4 to 5 liters with exercise/ambulation. The Pt. reviewed the medication list he/she maintain and stated, the Physician ordered this O2 dosage on 8/19/20. The POC lacked the correct dosage of O2. During the same home visit on 2/8/21, a list of the patient's medications were observed and included, "Mucinex 1200 mg 1 tab a day, Centrum Silver Multivitamin 1 tab a day and Flonase 1 spray in each nostril 1 time a day, the Pt. stated these medications had been taken for the past 6 months; and Ipratropium Bromide 0.5 mg Albuterol Sulfide 3 mg by nebulizer 2 to 3 times a day, the Pt. stated this medication has been taken this medication for the past 2 years. The PsOC effective 12/3/20 and 2/1/21 lacked Mucinex, Centrum Silver Multivitamin, Flonase and Ipratropium Bromide - Albuterol Sulfide. 2. Pt. #2. SOC 1/30/21. Diagnoses: Not Elsewhere Classified Initial Disruption of External Operation (Surgical) Wound and Personal History of Malignant Neoplasm of Breast. A home visit was conducted on 2/8/21 at 2:50 PM with E #2. During the home visit, the patient's medications were observed and an interview was conducted with the Pt. and caregiver. The medication "Anastrozole 1 mg every day by mouth" was observed, the Pt. stated this medication has been taken for the past 7 years; and Multivitamin 1 tab daily by mouth, the caregiver stated this medication has been taken for the past 5 years. The caregiver also stated, "The nurse has looked at the medicines" and is aware of what the Pt. take. The clinical record was reviewed on 2/8/21 at 2:50 PM and contained the POC effective 1/30/21 which lacked Anastrozole and Multivitamin. 3. Pt. #6. SOC 7/3/20. Diagnoses: Chronic Obstructive Pulmonary Disease with Acute Exacerbation and Chronic Obstructive Pulmonary Disease with Acute Respiratory Infection. The closed clinical record was reviewed on 2/9/21 at 12:30 PM. The record contained the POC for the cerfication period of 7/3/20 to 8/31/20 which required the SN: "...per PICC line. Flush IV access with 10 ml saline before and after infusion followed by Heparin. SN to perform sterile dressing changes to Rt. jugular PICC line using aseptic technique..." The POC lacked the dose of Heparin to flush the PICC line, a description and frequency for the dressing changes to the PICC line. The record contained the POC effective 7/3/20 and included that the Pt. received DME: Tub/Shower Bench, Walker, intravenous medications, and PICC line supplies through the Rt. jugular PICC line. The POC lacked the name and phone number of the DME supplier that provided the Tub/Shower Bench, Walker, intravenous medications, and PICC line supplies. 4. During an interview with the DON on 2/10/20 at 2:30 PM, the DON confirmed the above findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician. This ELEMENT is not met as evidenced by: . A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure all Pt. medications and treatments were ordered by the Physician. This was found in 3 of 7 (Pts. #5, 7, and 1) clinical records reviewed. Findings include: 1. Pt. #5. SOC 1/18/21. Primary Diagnosis: Aftercare Following Surgery for Neoplasm. The clinical record was reviewed on 2/9/21 at 2:30 PM. The record included a SN visit note dated 2/4/21, which contained "...Mediport also got infected and was removed a few days ago, started on po antibiotics..." The record lacked documentation the SN obtained a Physician's order for the antibiotic, including its name, dosage, and duration of therapy. 2. Pt. #7. SOC 12/30/19. Primary Diagnosis: Chronic Obstructive Pulmonary Disease with Acute Exacerbation. The clinical record was reviewed on 2/10/21 at 9:30 AM. The record included a SN visit note dated 5/7/20, which contained "...UA which showed UTI. Pt. started on po antibiotics today..." The record lacked documentation the SN obtained a Physician's order for the antibiotic, including its name, dosage, and duration of therapy. 3. Pt. #1. SOC 12/3/20. Diagnoses: Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Chronic Obstructive Pulmonary Disease with Acute Respiratory Infection and Unspecified Organism Pneumonia. The clinical record was reviewed on 2/9/21 at 9:15 AM. The record contained the SN visit notes dated 12/16/20, 12/19/20, 12/21/20 and 12/28/20. Each visit note included documentation the SN removed the old dressing to the right chest mediport, inserted a new needle into the mediport, flushed the mediport with Normal Saline then Heparin and applied a new dressing to the site. As of 2/9/21, the record lacked Physician orders for the RN to perform the care indicated above from 12/16/20 to 12/28/20. 4. During an interview with the DON on 2/9/21 at 1:35 PM and 2:30 PM, the DON confirmed the record lacked Physician orders for the medications and treatments identified above.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: . A. Based on staff interview, clinical record review, and review of Agency policies, and staff interview, it was determined the Agency failed to ensure it developed and implemented a policy regarding Pt. screening and administration of influenza and pneumococcal vaccines. This was found in 7 of 7 clinical records reviewed. Findings include: 1. During the entrance interview with the DON on 2/8/21 at 10:30 AM, the DON stated the RN should ask the Pt. at the SOC about his/her influenza and pneumococcal vaccine status, and document this information on the SOC assessment. 2. The clinical records of the following Pts. were reviewed from 2/9/21 at 9:15 AM through 2/10/21 at 9:30 AM: Pt. #1 SOC 12/3/20. Pt. #2 SOC 1/3/21. Pt. #3 SOC 1/31/21. Pt. #4 SOC 1/28/21. Pt. #5 SOC 1/18/21. Pt. #6 SOC 7/3/20. Pt. #7 SOC 12/30/19. These records lacked information on the Patients' SOC assessment regarding the Patients' influenza and pneumococcal vaccine status. 2. The Agency's "Policy and Procedure Manual" was reviewed on 2/9/21 at 2:00 PM. This manual contained a section titled "Agency Influenza Vaccination Program (Insert Agency-Specific Vaccination Program)." However, there was no policy inserted into the manual behind this section regarding Pt. screening/administration of influenza and pneumococcal vaccinations. 3. During an interview with the DON on 2/10/21 at 1:35 PM, the DON confirmed the above findings.

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: . A. Based on a review of clinical records, the Agency's COVID Infection binder and staff interview, it was determined the Agency failed to ensure staff screen Pts. for COVID-19, prior to providing care and/or service. This was found in 5 of 6 (Pts. # 1, 2, 3, 4, and 7) clinical records reviewed, wherein Pt. COVID-19 screening was required. Findings include: 1. Pt. #1. SOC 12/3/20. Diagnoses: Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Chronic Obstructive Pulmonary Disease with Acute Respiratory Infection and Unspecified Organism Pneumonia. The clinical record was reviewed on 2/9/21 at 9:15 AM. The record contained the weekly SN visit notes indicating service was provided from 12/10/20 to 12/28/20, 1/13/21 and 1/18/21. The record lacked documentation the SN screened Pt. #1 for COVID-19, prior to the visits indicated above. 2. Pt. #2. SOC 1/30/21. Diagnoses: Not Elsewhere Classified Initial Disruption of External Operation (Surgical) Wound and Personal History of Malignant Neoplasm of Breast. The clinical record was reviewed on 2/8/21 at 2:50 PM. The record contained the SN visit note dated 2/3/21 indicating service was provided. The record lacked documentation the SN screened Pt. #2 for COVID-19, prior to the visit indicated above. 3. Pt. #3. SOC 1/31/21. Diagnoses: Pressure Ulcer of Sacral Region, Stage 4, and Type 2 Diabetes Mellitus. The clinical record was reviewed on 2/9/21 at 12:45 PM. The record contained documentation the SN provided service on 1/31/21, the Physical Therapist provided services on 2/2/21, and the Occupational Therapist provided services on 2/2/21 and 2/4/21. The record lacked documentation COVID-19 Pt. screening was done prior to any of these visits. 4. Pt. #4. SOC 1/28/21. Primary Diagnosis: Multiple Fracture of Ribs, Left Side. The clinical record was reviewed on 2/9/21 at 1:50 PM. The record contained documentation the SN provided service on 1/28/21. The record lacked documentation COVID-19 Pt. screening was done prior to this visit. 5. Pt. #7. SOC 12/30/19. Primary Diagnosis: Chronic Obstructive Pulmonary Disease with Acute Exacerbation. The clinical record was reviewed on 2/10/21 at 9:30 AM. The record contained documentation the SN provided services on 4/9/20, 4/16/20, 4/23/20, 5/7/20, 5/14/20, 5/21/20, 5/28/20, and 6/6/20. The record also included documentation the Home Health Aide provided services on 4/23/20, 5/2/20, 5/9/20, 5/16/20, 5/23/20, 5/30/20, and 6/6/20. The record lacked documentation COVID-19 Pt. screening was done prior to any of these visits. 6. The Agency's COVID Infection binder was reviewed on 2/9/21 at 1:50 PM. The binder included, "Guidance for Infection Control and Prevention Concerning Coronavirus Disease 2019 (COVID-19) in Home Health Agencies (HHA)" which required: "When making a home visit, HHA's should identify patients at risk for having COVID-19 infection before or immediately upon arrival to the home. They should ask patients about the following: 1. International travel within the last 14 days... 2. Signs or symptoms of a respiratory infection... 3. In the last 14 days, has had contaxt with someone with or under investigation for COVID-19, or are ill with respiratory illness. 4. Residing in a community where community-based spread of COVID-19 is occuring..." 7. During the entrance interview with the DON on 2/8/21 at 10:30 AM, the DON stated for Pts.: "On the phone we ask the day before the visit, the COVID screening questions. On the day of the visit prior to giving care, we ask the same questions...This is documented in the visit note, the Interventions section on the very bottom..." 8. During interviews with the DON on 2/10/21 at 1:35 PM and 2:30 PM, the DON confirmed the above findings.

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: . A. Based on the staff interview, the Discharge Patients census report and review of the Agency's COVID Infection binder, it was determined the Agency failed to establish an Infection Surveillance Program and policies relative to COVID-19 for Pts. and staff. This has the potential to impact all Pts. and staff within the Agency. Findings include: 1. During the entrance interview with the DON on 2/8/21 at 10:30 AM, the DON stated the Agency had several Pts. discharged from the Agency that tested positive for COVID-19. 2. On 2/9/21 at 9:10 AM, the DON presented the "Discharge Patients" census report for Pts. discharged from the Agency from 1/1/20 to 12/31/20. The DON placed a mark next to two Pt. names indicating the Pts. were COVID-19 positive. 3. The Agency's COVID Infection binder was reviewed on 2/9/21 at 1:50 PM, the binder lacked documentation of an Infection Surveillance plan. 4. During an interview with the DON on 2/9/21 at 2:30 PM, the DON confirmed the Agency lacked an Infection Surveillance plan.

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: . A. Based on staff interview and review of the Agency's COVID Infection binder, it was determined the Agency failed to provide ongoing education related to infection control guidance for COVID-19. This has the potential to affect all Pts. and staff within the Agency. Findings include: 1. During an interview with the DON on 2/9/21 at 2:15 PM, the DON stated the Agency provided staff in-service education, and presented documentation of a staff in-service conducted on 3/23/20 for "Using PPE, Hand Hygiene". The DON stated the staff can complete other training through "...(Agency's electronic medical record) and read CDC information online as it becomes available". The Agency lacked documentation of staff in-services pertaining to other infection control prevention measures for COVID-19, clinical care guidance during the COVID-19 pandemic, conducting a home visit for a Pt. diagnosised with COVID-19 (Pt. #6. SOC 7/3/20) and other education pertaining to COVID-19. 2. The Agency's COVID Infection binder was reviewed on 2/9/21 at 1:50 PM, the binder lacked documentation that any education was provided to staff. 3. During an interview with the DON on 2/9/21 at 2:15 PM, the DON confirmed the Agency failed to provide ongoing staff education related to infection control guidance for COVID-19.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: . A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure the RN created a care plan for the Home Health Aide. This was found in 1 of 1 (Pt. #7) clinical records reviewed wherein Home Health Aide services were provided. Findings include: 1. Pt. #7. SOC 12/30/19. Primary Diagnosis: Chronic Obstructive Pulmonary Disease with Acute Exacerbation. The clinical record was reviewed on 2/10/21 at 9:30 AM. The record included a Home Health Aide Care Plan dated 2/12/20, which indicated the Home Health Aide visit frequency was once a week for three weeks. The record lacked documentation the RN created a new Home Health Aide Care plan to take effect after this time period. The record also contained documentation the Home Health Aide continued to provide services on 4/23/20, 5/2/20, 5/9/20, 5/16/20, 5/23/20, 5/30/20, and 6/6/20. The record lacked a Home Health Aide Care Plan for the services provided from 4/23/20 to 6/6/20. 2. During an interview with the DON on 2/10/21 at 1:35 PM, the above findings were confirmed.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(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 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 §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: . A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure the Home Health Aide was supervised by the RN every 14 days. This was found in 1 of 1 (Pt. #7) clinical records reviewed, wherein Home Health Aide services were provided. Findings include: 1. Pt. #7. SOC 12/30/19. Primary Diagnosis: Chronic Obstructive Pulmonary Disease with Acute Exacerbation. The clinical record was reviewed on 2/10/21 at 9:30 AM. The record contained documentation the Home Health Aide provided services on 4/23/20, 5/2/20, 5/9/20, 5/16/20, 5/23/20, 5/30/20, and 6/6/20. The record lacked documentation the RN provided supervision of the Home Health Aide during this time period. 2. During an interview with the DON on 2/10/21 at 1:35 PM, the DON confirmed the above findings.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: . A. Based on observation and interview during home visits, clinical record review, Agency policy review and staff interview, it was determined the Agency failed to ensure the clinical record contained accurate Medication Records. This was found in 1 of (Pts. #1) home visit conducted with the RN. Findings include: 1. Pt. #1. SOC 12/3/20. Diagnoses: Chronic Obstructive Pulmonary Disease with Acute Exacerbation, Chronic Obstructive Pulmonary Disease with Acute Respiratory Infection and Unspecified Organism Pneumonia. A home visit was conducted on 2/8/21 at 1:30 PM with E #1. During the home visit, an observation was made of the patient's medication list which included: Prozac 20 mg twice a day. During an interview with the Pt., he/she stated the medication was "changed from once a day to twice a day 3 weeks ago". The clinical record was reviewed on 2/9/21 at 9:15 AM. The record contained the "Medication Profile" form last updated on 2/1/21 which included: "Prozac 20 MG Oral Capsule 1 Cap Daily By mouth (PO). As of 2/9/21, the Medication Profile was inaccurate. 2. The Agency policy titled, "Medication Profile" was reviewed on 2/11/21 at 9:29 AM. The policy required: "...Patient receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications ..." 3. During an interview with the DON on 2/10/21 at 1:35 PM and 2:30 PM, the DON stated the SN is required to perform medication reconciliation every visit, and medication changes are indicated on the Medication Profile form.

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: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to send a copy of the transfer summary to the Physician. This was found in 1 of 2 (Pt. #6) closed clinical records reviewed. Findings include: 1. Pt. #6. SOC 7/3/20. Diagnoses: Chronic Obstructive Pulmonary Disease with Acute Exacerbation and Chronic Obstructive Pulmonary Disease with Acute Respiratory Infection. The closed clinical record was reviewed on 2/9/21 at 12:30 PM. The record contained the Agency's transfer assessment form completed by the RN and dated 7/13/20. As of 2/9/21, the record lacked any documentation a copy of the transfer summary was sent to the Physician. 2. During an interview with the DON on 2/10/20 at 2:30 PM, the DON confirmed the Agency failed to send a copy of the transfer summary to the Physician.