Every finding on record at Cas Home Health Care

Based on the findings of an unannounced onsite Medicare recertification survey conducted February 27, 2023 through March 2, 2023, CAS Home Health Care Inc. was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - 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 a review of agency policies, and an interview with the director of nursing and chief executive officer, the agency failed to provide documentation that the emergency preparedness plan was reviewed and updated every two (2) years nor that a documented, facility-based and community-based risk assessment was completed. Findings include: A review of the Emergency Preparedness Plan 5.40 on February 28, 2023 at approximately 3:00 PM found that the Emergency Preparedness Plan (EPP) was last updated on 04/01/2020. There was no evidence that the EPP was reviewed and updated in 2022. A review of the Emergency Preparedness Policy and Procedure on February 28, 2023 at approximately 3:00 PM found that the process for conducting a hazard vulnerability analysis (HVA) was present, but there was no evidence that the HVA (risk assessment) was actually completed. An interview conducted with the director of nursing and chief executive officer on March 2, 2023 starting at 2:30 PM confirmed the above findings.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on a review of agency policy, and an interview with the director of nursing and chief executive officer, the agency failed to demonstrate that the emergency preparedness communication plan included the Names and Contact Information for the following: Staff, Entities providing services under arrangement, Patients' physicians and Volunteers. Findings include: A review of the Emergency Preparedness Plan 5.40, and the Emergency Preparedness Policy and Procedure on February 28, 2023 at approximately 3:00 PM found that neither the Emergency Preparedness Plan nor the Emergency Preparedness Policy and Procedure included the names and contact information for agency staff and patients' physicians. An interview conducted with the director of nursing and chief executive officer on March 2, 2023 starting at 2:30 PM confirmed the above findings.

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 a review of personnel files (PF), agency policy, and an interview with the director of nursing and chief executive officer, the agency failed to demonstrate that initial training in emergency preparedness policies and procedures was provided to newly hired employees. Eight (8) of eight (8) personnel files did not meet the requirement: PF#1, PF#2, PF#3, PF#4, PF#5, PF#6, PF#7, and PF#8. Findings Include: A review of the Emergency Preparedness Plan 5.40 on February 28, 2023 at approximately 3:00 PM, reads in part, "Provide instruction and training employees on how to handle environmental disasters/emergencies during orientation and annually thereafter." A review of personnel files (PF) was conducted on March 1, 2023 starting at approximately 9:30 AM. The date of hire (DOH) is indicated below. PF#1 DOH 07/02/2021 did not contain evidence that training in emergency preparedness policies and procedures was provided at the time of hire or thereafter. PF#2 DOH 06/14/2021 did not contain evidence that training in emergency preparedness policies and procedures was provided at the time of hire or thereafter. PF#3 DOH 12/14/2022 did not contain evidence that training in emergency preparedness policies and procedures was provided at the time of hire. PF#4 DOH 08/05/2021 did not contain evidence that training in emergency preparedness policies and procedures was provided at the time of hire or thereafter. PF#5 DOH 10/10/2022 did not contain evidence that training in emergency preparedness policies and procedures was provided at the time of hire. PF#6 DOH 09/01/2022 did not contain evidence that training in emergency preparedness policies and procedures was provided at the time of hire. PF#7 DOH 06/16/2022 did not contain evidence that training in emergency preparedness policies and procedures was provided at the time of hire. PF#8 DOH 11/26/2021 did not contain evidence that training in emergency preparedness policies and procedures was provided at the time of hire or thereafter. An interview conducted with the director of nursing and chief executive officer on March 2, 2023 starting at 2:30 PM confirmed the above findings.

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 a review of the Emergency Preparedness documents provided by the agency, and an interview with the director of nursing, the agency failed to provide evidence that the emergency preparedness plan was tested annually. Findings Include: A review of the home health agency's emergency preparedness documents on February 28, 2023 at approximately 3:00 PM did not contain any evidence that exercises to test the emergency preparedness plan were conducted annually. An interview conducted with the director of nursing and chief executive officer on March 2, 2023 starting at 2:30 pm confirmed the above findings.

Based on the findings of an unannounced onsite Medicare recertification survey conducted February 27, 2023 through March 2, 2023, CAS Home Health Care Inc. was found not to be in compliance with the following requirement of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on a review of clinical records (CR), the agency's patient admission packet, and an interview with the director of nursing and chief executive officer, the agency failed to provide the patient with the names, addresses and telephone numbers of the following Federally-funded and State-funded entities that service the area where the patient resides: Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. Seven (7) of seven (7) CR's did not meet the requirement: CR#1, CR#2, CR#3, CR#4, CR#5, CR#6, and CF#7. Findings include: A review of the Patient Admission Packet on February 28, 2023 at approximately 10:00 AM found that the Admission Packet, which is provided to patients at the start of care, did not contain the names, addresses and telephone numbers of the following Federally-funded and State-funded entities that service the area where the patient resides: Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. A review of clinical records (CR) was conducted on February 27, 2023 starting at approximately 10:30 AM, and again on February 28, 2023 starting at 9:00 AM. The start of care (SOC) is indicated below. CR#1 SOC 12/15/2022 did not contain evidence that the patient received the names, addresses and telephone numbers of the following Federally-funded and State-funded entities that service the area where the patient resides: Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#2 SOC 09/13/2022 did not contain evidence that the patient received the names, addresses and telephone numbers of the following Federally-funded and State-funded entities that service the area where the patient resides: Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#3 SOC 07/25/2017 did not contain evidence that the patient received the names, addresses and telephone numbers of the following Federally-funded and State-funded entities that service the area where the patient resides: Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#4 SOC 03/11/2022 did not contain evidence that the patient received the names, addresses and telephone numbers of the following Federally-funded and State-funded entities that service the area where the patient resides: Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#5 SOC 04/27/2021 did not contain evidence that the patient received the names, addresses and telephone numbers of the following Federally-funded and State-funded entities that service the area where the patient resides: Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#6 SOC 12/12/2022 did not contain evidence that the patient received the names, addresses and telephone numbers of the following Federally-funded and State-funded entities that service the area where the patient resides: Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. CR#7 SOC 08/01/2022 did not contain evidence that the patient received the names, addresses and telephone numbers of the following Federally-funded and State-funded entities that service the area where the patient resides: Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and Quality Improvement Organization. An interview conducted with the director of nursing and chief executive officer on March 2, 2023 starting at 2:30 PM confirmed the above findings.

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 a review of clinical records (CR), agency policies, and an interview with the director of nursing and chief executive officer, the agency failed to provide the patient and the patient's representative with information regarding the processes by which patient transfer and discharge can occur. Seven (7) of seven (7) CR did not meet the requirement: CR#1, CR#2, CR#3, CR#4, CR#5, CR#6, and CR#7. Findings include: A review of the Transfer and Referral Policies 3.31 and 3.31.10, and the Discharge/Termination or Reduction of Services Policy 3.30 conducted on March 2, 2023 at approximately 10;30 AM found that the policies lacked language outlining home health agency requirements for transfer and discharge of a patient. A review of the Patient Rights document conducted on February 28, 2023 at approximately 10:00 AM found that the document, which is provided to patients at the start of care, did not contain information regarding the processes by which a home health agency may transfer or discharge a patient. A review of clinical records (CR) was conducted on February 27, 2023 starting at approximately 10:30 AM, and again on February 28, 2023 starting at 9:00 AM. The start of care (SOC) is indicated below. CR#1 SOC 12/15/2022 did not contain evidence that the patient and patient's representative were informed of the transfer and discharge processes. The patient rights document contained in the CR lacked the required information outlining the processes by which transfer and discharge may occur for a home health agency patient, and there was no other evidence to support that the patient received the information in another format. CR#2 SOC 09/13/2022 did not contain evidence that the patient and patient's representative were informed of the transfer and discharge processes. The patient rights document contained in the CR lacked the required information outlining the processes by which transfer and discharge may occur for a home health agency patient, and there was no other evidence to support that the patient received the information in another format. CR#3 SOC 07/25/2017 did not contain evidence that the patient and patient's representative were informed of the transfer and discharge processes. The patient rights document contained in the CR lacked the required information outlining the processes by which transfer and discharge may occur for a home health agency patient, and there was no other evidence to support that the patient received the information in another format. CR#4 SOC 03/11/2022 did not contain evidence that the patient and patient's representative were informed of the transfer and discharge processes. The patient rights document contained in the CR lacked the required information outlining the processes by which transfer and discharge may occur for a home health agency patient, and there was no other evidence to support that the patient received the information in another format. CR#5 SOC 04/27/2021 did not contain evidence that the patient and patient's representative were informed of the transfer and discharge processes. The patient rights document contained in the CR lacked the required information outlining the processes by which transfer and discharge may occur for a home health agency patient, and there was no other evidence to support that the patient received the information in another format. CR#6 SOC 12/12/2022 did not contain evidence that the patient and patient's representative were informed of the transfer and discharge processes. The patient rights document contained in the CR lacked the required information outlining the processes by which transfer and discharge may occur for a home health agency patient, and there was no other evidence to support that the patient received the information in another format. CR#7 SOC 08/01/2022 did not contain evidence that the patient and patient's representative were informed of the transfer and discharge processes. The patient rights document contained in the CR lacked the required information outlining the processes by which transfer and discharge may occur for a home health agency patient, and there was no other evidence to support that the patient received the information in another format. An interview conducted with the director of nursing and chief executive officer on March 2, 2023 starting at 2:30 PM confirmed the above findings.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on a review of clinical records (CR), agency policy, and an interview with the director of nursing and chief executive officer, the agency did not demonstrate that a registered nurse conducted an initial assessment visit within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner-ordered start of care for three (3) of seven (7) records reviewed: CR#1, CR#2, and CR#4. Findings include: A review of the Admission of Consumers to CAS Home Health Care Policy 3.10.30 conducted on March 1, 2023 at approximately 2:30 PM, reads in part, "assessments shall be conducted in a timely manner but must be conducted within 48 hours of the referral being made. If CAS Home Health Care is unable to conduct an assessment within the time frame requested, the following shall be contacted immediately: physician, referral source, and individual who has been referred." A review of clinical records (CR) was conducted on February 27, 2023 starting at approximately 10:30 AM, and again on February 28, 2023 starting at 9:00 AM. The start of care (SOC) is indicated below. CR#1: SOC 12/15/2022. The referral date documented on the Outcome and Assessment Information Set (OASIS) was 12/06/2022. The initial assessment was not completed until 12/15/2022, nine (9) days after the referral date. There was no specific SOC date ordered by the physician as noted on the OASIS. The OASIS assessment noted that the discipline of the person completing the assessment was a physical therapist for a case whereby both skilled nursing and physical therapy were ordered. The OASIS assessment was electronically signed by a registered nurse (RN). The CR contained a second non-electronic "medical" comprehensive assessment form which was developed by the home health agency (HHA), completed and signed by an RN on 12/15/2022. CR#2 SOC 09/13/2022. The referral date documented on the OASIS was 09/09/2022. The initial assessment was not completed until 09/13/2022, four (4) days after the referral date. There was no specific SOC date ordered by the physician as noted on the OASIS. CR#4 SOC 03/11/2022. The referral date documented on the jHAVEN (Home Assessment Validation and Entry System) was 03/02/2022. The initial assessment was not completed until 03/11/2022, nine (9) days after the referral date. There was no specific SOC date ordered by the physician as noted on the jHAVEN. An interview conducted with the director of nursing and chief executive officer on March 2, 2023 starting at 2:30 PM confirmed the above findings.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on a review of clinical records (CR), agency policies, and an interview with the director or nursing, the agency failed to complete a comprehensive assessment within five (5) days of the end of the certification period for three (3) of seven (7) CR's reviewed: CR#3, CR#4, and CR#7. Findings include: A review of the following policies was conducted on March 1, 2023 starting at 12:00 PM: Consumer Reassessments Policy 3.10 reads in part, "CAS Home Health Care Nursing Management Team assigns follow-up assessments based on the initial assessment date to assure that the assessment falls within the 60-day period." In-Home Orders Policy 3.13 states in part, ensuring that POC's are updated by the physician every 60 days or more frequently, if indicated." A review of CR's was conducted on February 27, 2023 starting at approximately 10:30 AM, and again on February 28, 2023 starting at 9:00 AM. The Start of Care (SOC) and CMS-485 Home Health and Certification Period (CP) are shown below. CR#3 SOC 07/25/2017 and CP 01/26/2023 to 03/26/2023 contained no documentation of a comprehensive assessment being completed within 5 days prior to the certification period (CP) beginning 01/26/2023. CR#4 SOC 03/11/2022 and CP 01/24/2023 to 03/24/2023 contained no documentation of a comprehensive assessment being completed within 5 days prior to the certification period (CP) beginning 01/24/2023. CR#7 SOC 08/012022 and CP 01/01/2023 to 03/01/2023 contained no documentation of a comprehensive assessment being completed within 5 days prior to the certification period (CP) beginning 01/01/2023. An interview conducted with the director of nursing and chief executive officer on March 2, 2023 starting at 2:30 PM confirmed the above findings.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on a review of clinical records (CR), agency policy, and an interview with the director of nursing and chief executive officer, the agency failed to ensure that the CMS-485 Home Health Certification and Plan of Care (POC) was signed by the physician within 30 days, per agency policy, for four (4) of seven (7) CR's reviewed: CR#1, CR#2, CR#3, and CR#4. Findings Include: A review of the Physician Orders for Consumer Policy 2.10.50 conducted on March 1, 2023 at approximately 1;30 PM reads, in part, "All physician orders must be reviewed and signed every 30 days in a 60-day certifying period." A review of clinical records (CR) was conducted on February 27, 2023 starting at 10:30 AM and again on February 28, 2023 starting at 9:00 AM. The Start of Care (SOC) and Certification Period (CP) are shown below. CR#1 SOC 12/15/2022 and CP 12/15/2022 to 02/12/2023 contained a POC that was signed by the physician on 02/10/2023, 57 days after the start of the above certification period. CR#2 SOC 09/13/2022 and CP 09/13/2022 to 11/11/2022 contained a POC that was signed by the physician, but not dated. CR#3 SOC 07/25/2017 and CP 01/26/2023 to 03/26/2023 contained a POC that was signed by the physician, but not dated. CR #4 SOC 03/11/2022 and CP 01/24/2023 to 03/24/2023 contained a POC that was signed by the physician on 03/01/2023, 35 days after the start of the above certification period. An interview with the director of nursing and chief executive officer on March 2, 2023 starting at 2:30 PM confirmed the above findings.

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 a review of clinical records (CR), agency policy, and an interview with the director of nursing and chief executive officer, the agency failed to provide care according to the CMS-485 Home Health Certification and Plan of Care (POC) for six (6) of seven (7) CR reviewed: CR#1, CR#2, CR#4, CR#5, CR#6, and CR#7. Findings include: A review of the following policies was conducted on March 1, 2023 at approximately 2:30 PM: In-Home Orders Policy 3.13 states in part, "In-Home Orders that do not include all the mandatory components must be validated with the prescriber before implemented;" and "Medication and treatment orders shall be implemented by a qualified nurse or therapist." Consumer Missed Visits Policy 3.140 reads in part, "If the missed visit impacts the health condition of the consumer, the qualifying physician is to be notified." Physician Orders Policy 2.10.50 reads in part, "All services provided by a home Health Care Agency must be ordered by a physician;" and "CAS Home Health Care ensures that all consumers receiving Home Health Care have a written physician order on file prior to care being provided." A review of clinical records was conducted on February 27, 2023 starting at approximately 10:30 AM, and again on February 28, 2023 starting at 9:00 AM. The Start of Care (SOC) and CMS-485 Home Health Certification and Plan of Care Period (CP) is shown below. Findings include: CR#1 SOC 12/15/2022 and CP 12/15/2022 to 02/12/2022 contained orders on the CMS-485 Home Health Certification and Plan of Care (POC), which was signed by the Registered Nurse (RN) on 12/15/2022, for the following: Skilled Nursing (SN) Visits: two times (2x) per week for nine (9) weeks; Physical Therapy (PT): 2x per week for nine (9) weeks; and Occupational Therapy (OT): 2x per week for nine (9) weeks. Missed Visits (MV) for Skilled Nursing (SN) occurred during the following weeks: Week of 12/19/22: 2 SN MV; Week of 12/26/22: 1 SN MV; Week of 01/02/23: 1 SN MV; Week of 01/09/23: 1 SN MV; Week of 01/16/23: 1 SN MV; Week of 01/23/23: 1 SN MV; Week of 01/30/23: 1 SN MV. The PT Assessment/Evaluation was not completed until 12/30/2022, fifteen days after the start of the CP. There were no PT visits prior to 12/30/22. Week of 01/23/23: 2 PT MV. There were no OT visits during the certification period. There were no notes addressing the reasons for the missed visits, potential impact, and/or any documentation of the physician being notified of the missed visits. The POC was not signed by the physician until 02/10/2023. There was a second POC in the clinical record for the same certification period as noted above, signed by the RN on 02/10/2022, which read in part, "SN once weekly (no duration), and PT to teach patient exercises." The second POC was signed by the physician on 02/17/23. There was no verbal order contained in the record as to when the frequency of the skilled nursing visits may have been changed during the certification period. CR#2 SOC 09/13/2022 and CP 09/13/2022 to 11/11/2022 contained orders on the CMS-485 Home Health Certification and Plan of Care (POC), which was signed by the Registered Nurse (RN) on 09/13/2022, for the following: SN 2x per week for 9 weeks. Missed Visits (MV) for Skilled Nursing (SN) occurred during the following weeks: Week of 10/03/22: 1 SN MV; Week of 10/17/22: 2 SN MV; Week of 10/31/22: 1 SN MV. There were no notes addressing the reasons for the missed visits, potential impact, and/or any documentation of the physician being notified of the missed visits. An order for PT Full Evaluation and Plan of Care was obtained on 10/03/2022 for PT to be started 2x per week for 6 weeks. Missed Visits (MV) for Physical Therapy (PT) occurred during the following weeks: Week of 10/17/22: 1 PT MV; Week of 10/24/22: 1 PT MV; Week of 10/31/22: 2 PT MV. Only one PT MV note was documented (11/2/22). The POC was signed by the physician but not dated. CR#4 SOC 03/11/2022 and CP 01/24/2023 to 03/24/2023 contained orders on the CMS-485 Home Health Certification and Plan of Care (POC) for the following: SN once weekly for pill box setup, and daily for medication administration for 1 hour per day. There was no duration for the visits noted on the POC. Missed Visits (MV) for Skilled Nursing (SN) occurred during the following weeks: Week of 01/23/23: 2 SN MV (1/28 and 1/29); Week of 2/6/23: 1 SN MV (2/11); Week of 2/13/23: 2 SN MV (2/15 and 2/17). There were no notes addressing the reasons for the missed visits, potential impact, and/or any documentation of the physician being notified of the missed visits. The length of the visits was 2 hours per day, instead of 1 hour per day as ordered on the POC, with the exception of the visit on 2/18/23 which was 1 hour in length. There was no physician order in the clinical record to increase the length of the daily visits from 1 hour to 2 hours per day. Physical Therapy (PT) visits were added via a physician order on 01/05/23 for 2x per week for 5 weeks. Missed Visits (MV) for PT occurred during the following week: Week of 01/23/22: 2 PT MV. There were no notes addressing the reasons for the missed visits, potential impact, and/or any documentation of the physician being notified of the missed visits. Physical Therapy was not re-ordered per the POC for the above certification period, but the patient was treated by PT on 01/30/23 and 02/02/23 as evidenced by the presence of PT notes in the clinical record. There was no order present in the CR for the PT visits on 01/30 and 02/02. CR#5 SOC 04/27/2021 and CP 12/26/2022 to 02/23/2023 contained orders on the CMS-485 Home Health Certification and Plan of Care (POC) for the following: SN 5 hours daily = 35 hours weekly. There was no duration for the visits noted on the POC. The HHA accommodated the visits based on the patient's needs, splitting the 5 hours per day into 2 shifts: One shift was 3 hours per day and the second shift was 2 hours per day. Missed Visits (MV) for Skilled Nursing (SN) occurred during the following weeks: Week of 02/06/23: On 2/7, the patient only received 2 hours of care via 1 shift; On 2/9, the patient only received 2 hours of care via 1 shift; Week of 02/13/2022: On 2/16, the patient only received 2 hours of care via 1 shift; Week of 02/20/23: On 02/20, the patient only received 2 hours of care via 1 shift; On 02/22, the patient only received 2 hours of care via 1 shift. There were no notes addressing the reasons for the missed visits, potential impact, and/or any documentation of the physician being notified of the missed visits. CR#6 SOC 12/12/2022 and CP 12/12/2022 to 02/09/2023 contained orders on the CMS-485 Home Health Certification and Plan of Care (POC) for the following: SN 2x per week for 9 weeks. Missed visits for skilled nursing occurred during the following weeks: Week of 12/29/22: 1 SN MV; Week of 01/02/23: 1 SN MV; Week of 01/09/23: 1 SN MV; Week of 01/16/23: 2 SN MV; Week of 1/23/23: 2 SN MV; Week of 1/30/23: 2 SN MV; Week of 02/06/23: 1 SN MV. There were no notes addressing the reasons for the missed visits, potential impact, and/or any documentation of the physician being notified of the missed visits. CR#7 SOC 08/01/2022 and CP 01/01/2023 to 03/01/2023 contained orders on the CMS-485 Home Health Certification and Plan of Care (POC) for the following: SN 2x per week for 1 hour. There was no duration for the visits noted on the POC. Missed visits for skilled nursing occurred during the following weeks: Week of 01/09/23: 1 SN MV; Week of 01/16/23: 2 SN MV; Week of 01/16/23: 2 SN MV; Week of 01/23/23: 2 SN MV; Week of 01/30/23: 1 SN MV. Week of 02/06/23: 2 SN MV; Week of 02/13/23: 2 SN MV; Week of 02/20/23: 2 SN MV. There were no notes addressing the reasons for the missed visits, potential impact, and/or any documentation of the physician being notified of the missed visits. The POC noted that the patient had chronic recurring wounds to both lower extremities but no open areas. Orders were noted to wash both legs with soap and water, then apply triamcinolone cream (used for eczema) to scaly areas and ammonium lactate (used for dry skin) to healthy skin, then wrap lower extremities with compression wraps. Nursing notes for 2/3/23, 1/13/23, and 1/6/23 did not contain documentation that the treatment, as ordered, was provided to the patient. An interview conducted with the director of nursing and chief executive officer on March 2, 2023 starting at 2:30 PM 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: Based on clinical home visit observations, a review of agency policies, and an interview with the director of nursing, the agency failed to follow its policy pertaining to infection control for one (1) of three (3) clinical home visits conducted: CR#4. Findings include: A review of the Care and Handling of Equipment Policy 5.90 conducted on March 1, 2023 at 10:00 AM reads in part, “Items that come in contact with the skin only and not with mucous membranes need to only be wiped down with a detergent or low-level disinfectant (e.g., crutches, canes, walkers, wheelchair, and blood pressure cuff).” A review of the Hygienic Measures in the Home and Office Policy 5.110 conducted on March 2, 2023 at 11:00 AM reads in part, “Clean all personal equipment used at the patient’s home before and after use and keep items bagged until time for use.” An on-site clinical home visit was conducted on February 28, 2023 at 7:10 AM at the home of CR#2. The nurse’s (PF#3) clinical bag was observed on the floor with no barrier beneath the bag. The nurse removed a blood pressure (BP) cuff from the bag, sanitized it with a disinfectant wipe, took the patient’s BP, and then returned the BP cuff to the bag without sanitizing it, separating it from other clean items in the bag, and/or placing the BP cuff into a separate bag. The nurse proceeded to check the patient’s oxygen saturation level with a pulse oximeter and after use, the nurse returned the pulse oximeter to the clinical bag without sanitizing it, separating it from other clean items in the bag, or placing the pulse oximeter into a separate bag. The nurse checked the patient’s lungs with a stethoscope. Upon completing the task, the nurse initially placed the stethoscope on the patient’s bed with no barrier beneath the stethoscope, then returned the stethoscope to the clinical bag without proper cleaning or storage. The observation revealed that there was no separation between clean equipment and equipment that was used and required sanitization. An interview conducted with the director of nursing and chief executive officer on March 2, 2023 starting at 2:30 PM confirmed the above findings.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on a review of agency policy, personnel files (PF) and an interview with the director of nursing and chief executive officer, the agency failed to provide Infection control education to staff at orientation, annually, and as needed to meet the staff's learning needs to provide adequate care; identify infection signs and symptoms; identify routes of infection transmission; appropriately disinfect/sanitize/transport equipment and devices used for patient care; and use proper medical waste disposal techniques, and that such education included instructions on how to implement current infection prevention/treatment practices in the home setting. Eight (8) of eight (8) PF's reviewed did not meet the requirement: PF#1, PF#2, PF#3, PF#4, PF#5, PF#6, PF#7, and PF#8. Findings include: A review of the following policies occurred on February 27, 2023 starting at approximately 2:30 PM. Annual Training Policy 4.50.50 reads, in part, "All employees shall be required to receive annual training on infection control." Infection Control Policy 5.50 reads, in part, "training and/or annual refreshers shall be provided to employees about how infection are contracted, transmitted, and how to control their spread." A review of personnel files (PF) was conducted on March 1, 2023 starting at approximately 9:30 AM. The date of hire (DOH) is indicated below. PF#1 DOH 07/02/2021 did not contain evidence that infection control education was provided at the time of hire. On 7/2/2022, the employee completed education on handwashing and methicillin-resistant staphylococcus aureus (MRSA) (an infection caused by staphylococcus bacteria) only. PF#2 DOH 06/14/2021 did not contain evidence that infection control education was provided at the time of hire. On 09/01/2022, the employee completed education on handwashing and methicillin-resistant staphylococcus aureus (MRSA) (an infection caused by staphylococcus bacteria) only. PF#3 DOH 12/14/2022 did not contain evidence that infection control education was provided at the time of hire. PF#4 DOH 08/05/2021 did not contain evidence that infection control education was provided at the time of hire. On 04/13/2022 the employee completed education on handwashing and methicillin-resistant staphylococcus aureus (MRSA) (an infection caused by staphylococcus bacteria) only. PF#5 DOH 10/10/2022 did not contain evidence that infection control education was provided at the time of hire. PF#6 DOH 09/01/2022 did not contain evidence that infection control education was provided at the time of hire. PF#7 DOH 06/16/2022 did not contain evidence that infection control education was provided at the time of hire. PF#8 DOH 11/26/2021 did not contain evidence that infection control education was provided at the time of hire or annually. An interview conducted with the director of nursing and chief executive officer on March 2, 2023 starting at 2:30 PM confirmed the above findings.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on a review of personnel files, agency policy, and an interview with the administrator and the chief executive officer, the agency failed to show evidence of a Coronavirus (COVID-19) staff vaccination policy, and failed to provide documentation related to the vaccination or exemption status for individuals who provide care, treatment or other services to patients for four (4) of eight (8) personnel files reviewed: PF#1, PF#5, PF#7 and PF#8. Findings include: A review of the COVID Exposure Policy on February 27, 2023 at 1:30 PM found that the policy only focused on processes related to COVID-19 exposure. The policy did not contain a process or plan for vaccinating all eligible staff, providing exemptions and accommodations for those who are exempt, and tracking and documenting staff vaccinations. An interview with the director of nursing (DON) and chief executive officer was conducted on March 2, 2023 at 2:15 PM. The DON stated that the agency has a process for tracking staff COVID-19 vaccinations via a spreadsheet that is maintained by office staff. A review of personnel files (PF) was conducted on March 1, 2023 starting at 09:30 AM. The date of hire is indicated below. PF#1 DOH 07/02/2021 did not contain documentation that the eligible individual received the COVID-19 vaccination nor was there documentation of a religious or medical exemption. PF#5 DOH 10/10/2022 did not contain documentation that the eligible individual received the COVID-19 vaccination nor was there documentation of a religious or medical exemption. PF#7 DOH 06/16/2022 did not contain documentation that the eligible individual received the COVID-19 vaccination nor was there documentation of a religious or medical exemption. PF#8 DOH 11/26/2021 did not contain documentation that the eligible individual received the COVID-19 vaccination nor was there documentation of a religious or medical exemption. An interview conducted with the director of nursing and chief executive officer on March 2, 2023 at 2:30 PM confirmed the above findings.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on a review of personnel files (PF), agency policies, and an interview with the director of nursing and chief executive officer, the agency failed to demonstrate the presence of the following: initial competency assessment for four (4) of eight (8) files reviewed: PF#1, PF#2, PF#3, and PF#6; annual competency assessment for one (1) of eight (8) files reviewed: PF#8; annual performance evaluation for one (1) of eight (8) files reviewed: PF#8; current cardiopulmonary resuscitation (CPR) certification for three (3) of eight (8) PF's reviewed: PF#1, PF#7, and PF#8; and screening for mycobacterium tuberculosis (TB) for eight (8) of eight (8) PF's reviewed: PF#1, PF#2, PF#3, PF#4, PF#5, PF#6, PF#7, and PF#8. Findings include: A review of the following policies occurred on February 27, 2023 from approximately 1:00 PM to 3:00 PM. Personnel Qualifications Policy 4.31 reads, in part, "all staff providing service to clients shall have and maintain current CPR certification." Licensure, Certification & Registration Policy 4.30 reads, in part, "Employees shall be responsible for ensuring licenses, certificates and/or registrations are kept current in accordance with applicable State laws and regulations," and "Proof of current licensures, certifications, and/or registrations shall be kept in the personnel files in the HR (Human Resources) office." Performance Assessment/Evaluation Policy 4.80 reads, in part, "A formal evaluation approach is a review that is conducted on an annual basis at a specific time and that is documented on an Employee Performance Evaluation form." Competency Evaluation/Hiring Employees Policy 4.60 reads, in part, "Director of Nursing/Designee/Managers shall conduct a minimal competency evaluation when newly hired as part of the orientation process and for annual performance assessment." Infection Control Policy 5.50 reads, in part, "Training and/or annual refreshers shall be provided to employees about how infections are contracted, transmitted and how to control their spread." Recruiting, Hiring & Rostering Policy 4.10 reads, in part, "Employees providing services to clients are required to have First Aid training and be CPR certified. Documentation showing currency of such certification is required," and "tuberculosis skin testing - the successful candidate (and all employees) shall be examined for tuberculosis by undergoing skin tests unless they are known to be positive reactors in which case, they shall have a chest x-ray instead." The template RN/LPN (registered nurse/licensed practical nurse) Competency Checklist and the home health aide performance competency template were also reviewed. The Centers for Disease Control and Prevention (CDC) and the National TB (Tuberculosis) Controllers Association released updated recommendations for Tuberculosis (TB) screening, testing, and treatment of health care personnel on May 17, 2019. These recommendations update the health care personnel screening and testing section of the 2005 CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Settings. All health care personnel should be screened for TB upon hire (i.e., preplacement). TB screening is a process that includes: a baseline individual TB risk assessment, a TB symptom evaluation, and a TB test (e.g., a TB single blood assay test or a two-step tuberculin skin test (TST), and additional evaluation for TB disease as needed. Health care personnel with a positive TB test result should receive a symptom evaluation and a chest x-ray to rule out TB disease. Additional workup may be needed based on those results. All health care personnel should receive TB education annually. TB education should include information on TB risk factors, the signs and symptoms of TB disease, and TB infection control policies and procedures. (CDC/MMWR/May 17, 2019/Vol.68/No.19). A review of personnel files (PF) was conducted on March 1, 2023 starting at 9:30 AM. The date of hire (DOH) is indicated below. PF#1 DOH 07/02/2021 contained a CPR card that expired 09/25/2022. There was no evidence of an initial competency assessment, and no evidence that a TB symptom screen was completed upon hire. Annual TB education only included information on TB signs and symptoms. There was no education regarding TB risk factors or TB infection control policies and procedures. PF#2 DOH 06/14/2021 did not contain evidence of an initial competency assessment, completion of a TB symptom screen and TB risk assessment upon hire, nor completion of annual TB education. PF#3 DOH 12/14/2022 did not contain evidence of an initial competency assessment or completion of a TB symptom screen and TB risk assessment upon hire. PF#4 DOH 08/05/2021 did not contain evidence of a completed TB symptom screen or TB risk assessment upon hire. Annual TB education only included information on TB risk factors. There was no education on TB signs and symptoms or TB infection control policies and procedures. PF#5 DOH 10/10/2022 did not contain evidence of an initial competency assessment, or completion of a TB symptom screen and TB risk assessment upon hire. PF#6 DOH 09/01/2022 contained a CPR card that expired on 11/27/2022. There was no evidence of an initial competency assessment. There was only a one step TST in the file, administered on 09/07/2022, and no evidence that a TB symptom screen or TB risk assessment was completed upon hire. PF#7 DOH 05/16/2022 contained a CPR card that expired on 10/05/2022. There was no evidence that a TB symptom screen or TB risk assessment was completed upon hire. PF#8 DOH 11/26/2021 did not contain evidence of CPR certification. There was no evidence of an annual competency assessment or performance evaluation conducted in 2022. The PF did not contain a completed TB symptom screen or TB risk assessment upon hire. Annual TB education only included information on TB risk factors. There was no education on TB signs and symptoms or TB infection control policies and procedures. An interview conducted with the director of nursing and chief executive officer on March 2, 2023 starting at 2:30 PM confirmed the above findings.