Every finding on record at Caregivers, Inc.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey 4F07B-H1 at the above-named Home Health Agency (HHA) from 07/19/2022 to 07/22/2022 resulted in the following deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on document review and staff interview, the home health agency (HHA) failed to maintain documentation of training and testing for emergency preparedness for HHA employees. This failure had the potential for home health staff to be unprepared to carry out the HHA's emergency plan. Findings Include: Document review of an undated agency policy titled, "Disaster/Emergency Preparedness," showed the purpose of the policy was to provide for continuity of care in the event of a natural or man-made disaster. The policy further showed that employees would be oriented on the emergency plan during the new hire process and annually. The agency would review the emergency plan annually and conduct and evaluate an emergency response. A review of the HHA Emergency Preparedness Plan on 07/20/22 at 3:29 PM, did not show documentation of a training and testing program for HHA employees. During an interview on 07/22/22 at 10:30 AM, the Administrator agreed the agency was not demonstrating training and testing with its employees. The Administrator further stated that the expectation was to follow the federal regulations regarding the emergency preparedness rules.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey 4F07B-H1 conducted at the above-named Home Health Agency (HHA) from 07/19/2022 to 07/22/2022 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited.

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 or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interviews, record reviews, and agency policy review, it was determined that the home health agency (HHA) failed to ensure individualized plans of care included all pertinent diagnoses for 2 (Patient 4 and Patient 5) of 17 patients reviewed and failed to ensure patient-specific interventions related to the primary diagnoses were included on the plan of care for 2 (Patient 2 and Patient 5) of 17 patients reviewed. Findings Included: 1. A review of an undated agency policy titled, "Care Planning," showed that every patient's plan of care (POC) should include the patient's principle diagnosis and other pertinent diagnoses. A review of Patient 4's, "Home Health Certification and Plan of Care (POC)," dated 05/05/22, showed the agency admitted Patient 4 on 05/05/22 with diagnoses that included traumatic ischemia of muscle (permanent damage to nerves and muscles), polyneuropathy (nerve damage), and depression. Further review showed that Patient 4 was taking levothyroxine (a medication used to treat thyroid issues) one time per day. The POC did not show any diagnosis related to thyroid issues. A review of Patient 5's, "Home Health Certification and Plan of Care (POC)," dated 07/01/22, showed the agency admitted Patient 5 on 07/01/22 with diagnoses that included acute pain due to trauma, type 2 diabetes mellitus (high levels of sugar in the blood), and back pain. Further review showed that Patient 5 was taking omeprazole (a medication used to treat gastroesophageal reflux disease [GERD-a chronic stomach disease]), one time per day and levothyroxine one time per day. The POC did not show any diagnoses related to GERD or thyroid issues. During a concurrent record review and interview conducted on 07/21/22 at 2:30 PM with the Director of Nursing (DON), the DON confirmed that Patient 4's POC dated 05/05/22 did not show a diagnosis related to thyroid issues and that Patient 5's POC dated 07/01/22 did not show any diagnoses related to GERD and thyroid problems. The DON stated that Patient 4's POC should have included a diagnosis related to thyroid issues and that Patient 5's POC should have included diagnoses related to GERD and thyroid problems. During an interview conducted on 07/22/2022 at 12:15 PM, the Administrator stated that the agency policy was that patient care plans should include pertinent diagnoses and acknowledged that the agency was not following its policy. 2. A review of an undated agency policy titled, "Care Planning," showed that every patient's POC should be individualized to meet the patient's needs. A review of Patient 2's, "Home Health Certification and Plan of Care (POC)," dated 05/05/22, showed that the agency admitted Patient 2 on 07/01/22 with a primary diagnosis of acute pain due to trauma. Patient 2's POC did not include any goals or interventions related to managing the patient's pain. A review of Patient 5's, "Home Health Certification and Plan of Care (POC)," dated 07/01/22, showed that the agency admitted Patient 5 on 07/01/22 with a primary diagnosis of acute pain due to trauma. Patient 5's POC did not include any goals or interventions related to managing the patient's acute pain. During a concurrent record review and interview conducted on 07/21/22 at 2:30 PM, the DON confirmed that Patient 2's POC dated 07/01/22 did not include goals and interventions related to Patient 2's primary diagnosis and that Patient 5's POC dated 07/01/22 did not include any goals or interventions related to the patient's primary diagnosis. The DON stated that the agency's expectation was that patients' POCs should include goals and interventions related to their primary diagnosis. During an interview conducted on 07/22/22 at 12:15 PM, the Administrator stated that the agency policy was that patient care plans should include goals and interventions related to the patients' primary diagnosis and acknowledged that the agency was not following its policy.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interviews, record reviews, and agency policy review, it was determined that the home health agency (HHA) failed to provide services as ordered by a physician for 1 (Patient 1) of 17 sampled patients. Patient 1 had a home health visit on 07/13/22 that included nursing services; however, there was not an order for Patient 1 to receive nursing services. Findings Included: A review of an undated agency policy titled, "Physician Orders/Plan of Care," showed that patients' care plans were to include an order for each service provided and that the purpose of the policy was to ensure that each patient's care was under the direction of a physician. A review of Patient 1's, "Home Health Certification and Plan of Care (POC)," dated 07/20/22, showed the agency admitted Patient 1 on 07/13/22 with diagnoses that included arthritis in both knees and depression. The POC did not include an order for nursing services. A review of Patient 1's, "OASIS-D1 Start of Care," showed that Patient 1 received nursing services during a visit on 07/13/22. During a concurrent record review and interview conducted on 07/22/22 at 9:45 AM, the Director of Nursing (DON) confirmed that Patient 1's POC dated 07/13/22 did not contain an order for nursing services and that Patient 1 received nursing services on 07/13/22. The agency was unable to provide a physician order for nursing services for Patient 1. During an interview conducted on 07/22/22 at 12:15 PM, the Administrator stated that the agency policy was that nursing services provided to patients required a physician's order and acknowledged that the agency was not following its policy.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on staff interviews, record review, and agency policy review, it was determined the home health agency (HHA) failed to ensure the revised plan of care reflected current information regarding medications for 1 (Patient 7) of 17 sampled patients. The facility failed to revise the plan of care for Patient 7 when there was a change in the dose of the patient's medication. Findings Include: A review of an undated agency policy titled, “Care Planning,” showed the Plan of Care (POC) would be revised as frequently as deemed necessary and based on on-going assessments of the patient. A review of Patient 7’s, “Home Health Certification and Plan of Care (POC),” dated 05/23/22, showed the agency admitted Patient 7 on 02/02/21 with diagnoses that included type 2 diabetes mellitus (high levels of sugar in the blood) and heart failure. Further review revealed that Patient 7 was taking carvedilol (a medication used to treat heart failure) 6.25 milligram (mg) one tablet by mouth twice per day and carvedilol 12.5 mg one tablet by mouth twice per day. During a concurrent record review and interview conducted on 07/22/22 at 10:30 AM, the Director of Nursing (DON) stated that Patient 7’s carvedilol 12.5 mg one tablet by mouth twice per day had been changed to Carvedilol 6.25 mg one tablet by mouth twice per day on 5/23/22. A review of Patient 7’s, “Patient Medication Review,” dated 05/26/22, showed that Patient 7’s carvedilol 12.5 mg one tablet by mouth twice per day had been changed to carvedilol 6.25 mg one tablet by mouth twice per day. During a concurrent record review and interview conducted on 07/22/22 at 11:30 AM, the DON confirmed the Patient 7’s POC had not been updated to show the updated carvedilol order identified in the “Patient Medication Review” assessment completed on 05/26/22. The DON stated that Patient 7’s POC should have been updated to reflect the current medication order. During an interview conducted on 07/22/22 at 12:15 PM, the Administrator stated that the agency policy was that patient care plans should be updated as needed based on current assessments and acknowledged that the facility was not following its policy.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on record review, agency policy review, and staff interview, the home health agency (HHA) failed to ensure 1 (Patient 16) of 17 sampled patients was discharged from therapy services by the appropriate discipline under supervision of the therapist. This failure had the potential for Patient 16 not to receive an appropriate summary of progress towards established goals and post-discharge instructions. Findings Include: A review of an undated agency policy titled, “Therapy Services,” showed the purpose of the policy was to ensure that all therapy responsibilities were clearly stated. The policy showed that services furnished by a qualified physical therapy assistant or qualified occupational therapy assistant may be furnished under the supervision of a qualified physical or occupational therapist, and approval of discharge from the supervising therapist must be documented in the clinical record by the assistant. A review of Patient 16’s clinical record on 07/21/22 at 12:49 PM revealed a start of care (SOC) date of 09/16/21. The diagnoses establishing the need for home health was spinal stenosis (a narrowing of the spinal column which compresses the spinal cord), rhabdomyolysis (a breakdown of skeletal muscle due to injury, which can lead to kidney damage), primary generalized arthritis, and abnormalities of gait and mobility. The plan of care (POC) contained orders for physical therapy (PT) visits at a frequency of one or two times per week for nine weeks and occupational therapy (OT) visits at a frequency of one or two times per week for four weeks. Review of a “PTA [Physical Therapist Assistant] Discharge Visit,” dated 11/04/21, showed that the patient had met the stated goals in the POC. The visit was digitally signed by a Certified Physical Therapist Assistant. Further review of the record showed no documentation of a discharge report from a Physical Therapist was found in Patient 16’s clinical record. In addition, a discharge visit titled, “COTA [Certified Occupational Therapist Assistant] Discharge Visit,” dated 11/03/2021, showed the patient had met 3 of 4 of the OT goals. The visit was digitally signed by a Certified Occupational Therapist. There was no documentation of a discharge report from an Occupational Therapist found in Patient 16’s clinical record. During an interview on 07/22/2022 at 9:42 AM, the Director of Nursing (DON) stated she believed the agency policy allowed for PTAs and COTAs to collaborate with the PTs and OTs to help with discharge planning. The DON stated this was why Patient 16 had COTA and PTA Discharge Visits included in the clinical record.