Every finding on record at Central Ohio Health Care Systems, LLC

EMERGENCY PREPAREDNESS SURVEY At the time of the emergency preparedness survey completed on 10/25/22, Central Ohio Health Care Systems is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Extended Recertification Survey The following deficiencies are based on the extended recertification survey completed 10/25/22. Central Ohio Health Care Systems is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C, Home Health Agencies.

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 review of QSO memo 22-09-ALL Attachment G, staff covid-19 vaccination status, and staff interview, the agency failed have policies for staff Covid-19 vaccination and mitigation strategies in place for unvaccinated staff and failed to ensure all staff were vaccinated for Covid-19 or had a qualifying religious or medical exemption. Eight (Staff Y, Staff J, Staff K, Staff L, Staff M, Staff N, Staff O and Staff P) of 34 staff members were unvaccinated or vaccination status was unknown. The agency had a staff vaccination rate of 76.5%. This had the potential to affect all 32 patients on the agency’s census. Review of QSO memo 22-09-ALL Attachment G, dated 01/14/22, revealed within 90 days of issuance of this memorandum, 100 percent of staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple vaccine series) or have been granted a qualifying exemption, or are identified as having a temporary delay as recommended by the Centers for Disease Control and Prevention (CDC). The memo also stated the home health agency (HHA) must develop and implement policies and procedures and the policies and procedures must include, at a minimum, 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; and 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. Review of the facility COVID-19 vaccination information provided by the Backup Administrator (BA) #99 on 10/12/22 at 12:47 PM revealed eight of 34 staff members, Staff Y, Staff J, Staff K, Staff L, Staff M, Staff N, Staff O and Staff P, did not receive a COVID-19 vaccination or their vaccine status was unknown, and none had a medical or religious exemption on file. The facility staff vaccination rate was 76.5 percent. At the time the information of staff vaccination was provided BA #99 stated the agency did not have policies in place for staff vaccination for Covid-19 and it was up to the staff. BA #99 also revealed there were no religious or medical exemptions on file for any staff members.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure nursing assessments were completed as ordered in the physician's ordered plan of care (485). This affected three (Patient #1, Patient #6 and Patient #7) of three patients reviewed for skilled nursing (SN) visits. The agency was providing SN services to 17 patients. The total agency census was 32. 1. Medical record review fpr Patient #1 revealed for the certification period of 08/19/22 to 10/17/22 Patient #1 was to receive SN visits one time per week. For the week of 09/25/22 Patient #1's electronic medical record did have a visit dated 09/26/22 however the note was a blank SN note. 2. Medical record review for Patient #6 revealed for the certification period of 08/18/22 to 10/16/22, Patient #6 was to receive SN visits 14 SN visits per week. Patient #6 had AM and PM visits documented daily with these exceptions: the PM SN note dated 09/19/22 was blank, the AM SN note dated 09/20/22 was blank, the PM note dated 09/26/22 was blank, the AM and PM notes dated 09/17/22 were both blank. 3. Medical record review for Patient #7 revealed for the certification period of 8/22/222 to 10/20/22, Patient #7 was to receive SN one time per week. For the week of 09/16/22, 09/20/22 and 09/27/22 the SN notes were blank. During interview on 10/12/22 at 3:35 PM Staff Y, Backup Administrator (BA) #99 and the agency Chief Executive Officer (CEO) stated all clinical nursing notes are in the Axxess. Axxess was the computerized medical records system. During interview on 10/12/22 at 8:59 AM, the Director of Nursing (DON) stated all clinical nursing notes are in the Axxess computerized charting system. During interview on 10/13/22 at 10:09 AM, the DON stated there was no policy in place for timely documentation.