Every finding on record at Community Homecare

A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Mexico Department of Health. An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 11/28/22 to 11/29/22 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation (CoP) under 42 CFR 484.102.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Mexico Department of Health. An unannounced on-site recertification survey conducted at the above-named Home Health Agency (HHA) from 11/28/22 to 11/29/22 resulted in noncompliance with two Conditions of Participation (G370, and G680) respective to the applicable CoP under 42 CFR 484, Subparts A through C and the following standard-level deficiencies listed below. Survey Dates: 11/28/22 to 11/29/22 Survey Census: 32 Sample Size: 7

Reporting OASIS information CFR(s): 484.45 Condition of participation: HHAs must electronically report all OASIS data collected in accordance with §484.55. This CONDITION is not met as evidenced by: Based on medical record review and staff interview, the agency did not complete a "Transfer OASIS [Outcome and Assessment Information Set]" or a "Resumption of Care OASIS" for one of seven patient (Patient (P) 5) records reviewed. The failure to complete and upload required OASIS assessments had the potential to impact the assessment of the patients needs and updates needed to the plan of care (POC). Review of P5's Electronic Medical Record (EMR) revealed a "Skilled Nurse Visit" dated 11/02/22 in the "Nursing" tab which revealed, "Daughter, …aids in medication administration. Reports stop of Lanoxin dated [sic] during hospital stay 10/24/2022 – 10/26/2022." Review of the "Nursing" tab failed to show that a "Transfer OASIS" for the admission to the hospital on 10/24/22 or a "Resumption of Care OASIS" following discharge on 10/26/22 had been completed. During an interview on 11/29/22 at 11:30 AM, the Director of Nursing (DON) confirmed that a "Transfer OASIS" and "Resumption of Care OASIS" had not been completed and stated he/she had not been aware that P5 had been hospitalized. Review of the agency policy titled, "Patient Admission to Inpatient Facility," dated 11/2010, revealed, "When an employee of Clovis/Community Homecare becomes aware that a client/patient has been admitted to an inpatient facility, the Clinical Services Administrator or designee shall … Complete Transfer to Inpatient OASIS." Review of the agency policy titled, "OASIS Client Data," dated 12/2010, revealed, "The Agency must electronically transmit accurate, completed, encoded and locked OASIS data … " Review of the agency policy titled, "Client Nursing Assessment," dated 11/2010, revealed, "The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than … within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests."

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on document review and interview, the agency did not provide to patients the correct state toll free home health telephone hot line number and hours of operation for complaints or questions about local HHAs. The failure to provide patients with the state contact information had the potential for patient right concerns or complaints about the agency to not be addressed. This had the potential to affect all 32 patients receiving services from this agency, with possible negative outcomes. Review of the folder containing documents provided to patients during the admission process revealed a document titled "Client Information on Incident Management" dated 10/2020 which stated, "An incident is when something bad happens to one of our clients. An incident can be suspected abuse, neglect, exploitation, or death of a client … if you feel that you are the victim of an incident, immediately contact Community Homecare at (575) 769-2243 or toll free at 1-800-559-2243, or the State of New Mexico Incident Management Bureau at (866)841-6691…" The document went on to describe the types of reportable incidents to call about which included abuse, death, environmental hazards, emergency services, and law enforcement intervention. The folder did not include information on how to contact the State of New Mexico Department of Health if a patient had a complaint about the services or care provided by the HHA that might not rise to the level of "an incident" as described above. The phone number listed in the document was not the correct information for complaints against a HHA. During an interview on 11/28/22, the Director of Nursing (DON) confirmed that the documents in the folder are the only documents provided to patients on admission and that the documents did not include the contact information for the State of New Mexico Department of H

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 medical record review, staff interviews, and review of the agency policy, the agency failed to ensure the Registered Nurse (RN) completed the initial assessment of patient needs within 48 hours of the referral date for four of seven patients (Patients (P) 3, 4, 5, and P6). Failure to assess the immediate care and support needs of patients while they wait for a complete and comprehensive assessment of needed services could cause a lapse in health and safety needs for all 32 patients receiving services from this agency, with possible negative outcomes. 1.Review of the agency policy titled, "Client Nursing Assessment," revised 11/2010, indicated, "Registered Nurses do initial nursing assessments on every client admitted to the home health agency. OASIS [Outcome and Assessment Information Set/the standardized assessment tool used for home health agency admissions] requirements will be fulfilled as part of the initial assessment for all patients…" Procedure- " The initial assessment visit must be held either within 48 hours or referral, or within 48 hours of the patient's return home, or on the date of the physician ordered start of care date." Review of the Electronic Medical Record (EMR) for P 3 was conducted with the Director of Nursing (DON) on 11/29/22 at 12:34 PM. Review of the EMR "Faxed Admission record” from the hospital care coordinator to the home health agency dated 10/21/22 indicated, "New referral for HHC (home health care). Please let me know if you can accept patient. Either home today or tomorrow…" Further review of the admission record from the hospital indicated on 10/21/22 the physician electronically signed orders for "Referral to Home Health." It further indicated a physician face to face encounter was conducted on 10/21/22 and the patient met the necessary home health requirements to receive skilled nursing services from home health. Review of a "Referral Checklist" for P3 provided by the DON indicated, the home health agency received the fax referral from the referring provider on 10/21/22 at 3:50 PM. Review of the "OASIS-D1 SOC [Start of Care]" in the EMR, dated 10/25/22, indicated P3 was discharged from the hospital on 10/22/22. The OASIS-D1 SOC revealed the start of care from the home health agency did not begin until 10/25/22 and the first initial RN assessment was not completed for P3 until 10/25/22 (which was three days after the initial referral was received by the home health agency on 10/21/22). Further review of the document revealed the RN signed the initial assessment as being completed on 10/25/22. During an interview on 11/29/22 at 12:34 PM, regarding when the initial assessment is to be completed by a RN, the DON stated, "The Start of care was 10/25/22. We received the initial faxed referral from the hospital on 10/21/22. The case manager at the hospital said she (P3) would be discharged from the hospital either on 10/21 or 10/22. The actual order from the physician was on 10/21/22. I did her initial assessment on 10/25/22. I don't have a communication note of any attempts to contact the case manager and/or family prior to 10/25/22 and we should have had something. All I have is the fax from the hospital with the referral date of 10/21/22. I don't remember the situation. I think the nephew may have said she (P3) had been discharged from the hospital on 10/22. From looking at the OASIS, it says she was discharged from the hospital on 10/22. I can see where we had a lack in the delay of care, and not getting the initial assessment completed as it should have been within those 48 hours of getting the referral." 2. Review of the EMR for P4 was conducted with the DON on 11/29/22 at 9:00 AM. Review of the EMR "Faxed Admission record" from the hospital to the home health agency dated 11/16/22 indicated, home health services were requested on 11/16/22. The documentation further indicated a referral to the home health agency was made on 11/16/22 for P4 to receive Skilled Nursing services, and physical therapy. Review of the "OASIS-D1 SOC" in the EMR, dated 11/22/22, indicated P4 was discharged from the hospital on 11/16/22 and the "Date of Referral" to the home health agency was also on 11/16/22. Further review of the “OASIS-D1 SOC” revealed the initial assessment was not completed by the RN until 11/22/22 (six days after the referral was made on 11/16/22). Review of a "Referral Checklist" for P4 provided by the DON indicated, the home health agency received the fax referral from the referring provider on 11/16/22 at 4:20 PM. Further review of the referral checklist indicated, "Left VM [voice mail] for [name of case manager] at hospital on 11/17." During an interview on 11/29/22 at 9:00 AM, the DON stated, "The initial referral was faxed to us from the hospital on 11/16/22, but there was no specific start of care date that I could see. We called the case manager at the hospital on 11/17 and left voice messages with no return call. We were trying to find out about a discharge date, because we thought he [P4] was still in the hospital." The DON then stated, "We didn't hear anything back. Then the family of P4 called us on 11/22/22 saying that he [P4] had already been discharged from the hospital back on 11/17/22." The DON stated, "We did not have any communication notes that the family contacted us, or that we contacted the family. The 48 hours of getting the initial RN assessment was not put in place because we were under the impression he was still in the hospital. We should have called the family to see if he [P4] was still in the hospital, but we did not. When we heard from the family on 11/22/22, we then submitted the insurance authorization. We got that back the same day and we then had our start of care on 11/22/22." During an interview on 11/29/22 at 10:00 AM, the RN stated, "We just admitted him last week and I did the initial assessment last week on the 22nd." 3.Review P5's EMR revealed a document titled, "Patient Referral Form" located in the "Misc." tab dated 10/13/22 which showed a referral for HHA services for skilled nursing. Review of documentation included with the referral revealed P5 was seen in ambulatory care at Roosevelt General Hospital in Portales, NM on 10/13/22. P5 was not admitted to the hospital and there is no documentation of a physician ordered SOC date. Review of the "OASIS-D1 Start of Care" located in the "Nursing" tab revealed P5 was seen for the initial HHA visit and admitted for services on 10/21/22 which is more than 48 hours after the referral. 4.Review of P6's EMR revealed a document titled, "Referral Orders" located in the "Misc." tab dated 07/22/22 for skilled nursing for dressing change to a wound on P6's lower abdomen measuring 8 centimeters (cm.) in height by 7 cm. in width by 1 cm. in depth. Review of documentation included with the referral revealed the referral had been received from a nurse practitioner during a clinic follow up visit following abdominal surgery. There was no evidence in the EMR of a specific SOC order date. Review of the "OASIS-D1 Start of Care" located in the "Nursing" tab revealed P6 was seen for the initial HHA visit and admitted for services on 07/28/22 which is more than 48 hours after the referral.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on medical record reviews, staff interviews and review of the agency Admissions packet, the agency failed to ensure two of seven patients (Patients (P2 and P4) and caregivers/representative of these patients were provided with a copy of written information to include visit schedules, and written information of frequency of visits the Home Health agency personnel would be providing. By not ensuring clear written visit schedules are provided by the Home Health Agency to the patients, and caregivers/representatives, would affect their quality of life and day to day living. Review of the agency "Admission Packet" revealed a document titled, "Participation in Plan of Care." Review of this document indicated, "I acknowledge that I was present and participated in forming my plan of care. My services and their proposed frequencies are as follows: SN [skilled nursing] x week, Expected Days: _. PT [physical therapy] x week, Expected Days: _. HHA [Home Health Aide] x week, Expected Days: _. My preferred times to receive care are: _." 1.Review of the "Oasis [Outcome and Assessment Information Set/the standardized assessment tool used for home health agency admissions]-D1 SOC [Start of Care]" located in the Electronic Medical Record (EMR) for P2, dated 11/18/22, indicated P2 would be receiving SN 1x/week for 8 weeks, and as needed, OT [Occupational Therapy] 2x/week for 8 weeks and evaluate and treat, and HHA2x/week for 8 weeks. Review of the "Home Health Certification and Plan of Care" located in the EMR for P2 dated 11/18/22, also indicated P2 would be receiving SN 1x/week for 8 weeks, OT 2x/week for 8 weeks and evaluate and treat, and HHA 2x/week for 8 weeks. During a home visit to P2's home on 11/28/22 from 3:00 PM to 3:45 PM, the patient's blue binder that was provided to the patient and caregiver/representative upon admission revealed no written information to include visit schedules, or written information of frequency of visits the home health agency personnel would be providing. During an interview on 11/28/22 at 3:15 PM, when the Home Health Aide (HHA) was asked about written documentation of the frequency of visits that are provided, the HHA stated, "There should be a calendar in the blue folder." Review of P2's blue binder that was provided by the caregiver/representative of P2 revealed no written information on the schedule of visits, or written information of the frequency of visits the home health agency personnel would be providing. At this time, the HHA stated, "I don't see a calendar in the folder. Usually, we will just call when we will be coming. Years ago, we used to keep our scheduled visits and a calendar in their blue binders, but I don't see one." During an interview on 11/28/22 at 3:45 PM, when the caregiver/representative of P4 was asked if he has ever received any written information regarding a schedule to visits, or written information of the frequency of visits the home health agency would be making, the caregiver/representative of P2 stated, "They did not go over a calendar or schedule of visits. No. They just said a nurse would be coming in and an aide. There was nothing written that I recall as far as specific dates and times of the visits." 2. Review of the "Oasis -D1 SOC" located in the EMR for P4, dated 11/22/22, indicated P4 would be receiving skilled nursing services one time a week for eight weeks. There were no specific days specified on the Oasis. Review of the "Home Health Certification and Plan of Care" located in the EMR for P4 dated 11/22/22, also indicated SN was to be received once a week for 8 weeks. There were no specified dates indicated when nursing services would be provided. During a home visit to P4's home on 11/29/22 from 10:00 AM to 10:45 AM, the patient's blue binder that was provided to the patient and caregiver/representative upon admission revealed no written information to include visit schedules, or written information of frequency of visits the home health agency personnel would be providing. During an interview on 11/29/22 at 10:15 AM, with P4 and the caregiver/representative of P4, P4 stated, "I don't recall being given any information on the schedule of visits. We just started with this home health agency last week. I came from the hospital and a lot has happened. I can't remember everything." During interview, the caregiver/representative of P4 stated, "We did not receive a calendar of visits. There is no calendar in this binder. We did not get a schedule of visits when we started getting home health. No." The caregiver/representative of P4 then stated, "Last week when the nurse came to our home, we spoke about how often a nurse would be coming, but I don't recall ever seeing an actual schedule. " During an interview on 11/29/22 at 11:17 AM, with the Director of Nursing (DON) regarding if patients and caregivers/representatives are receiving written information to include the schedule of visits and frequency of visits, the DON stated, "Upon admission the information regarding visit schedules and frequency of visits is discussed with the patient and caregiver/representative." The DON stated, "It should be in the admission packet. All we have is this document (referring to the Participation in Plan of Care) that we keep in each patients' binders here at the agency." The DON then stated, "We don't have any written documentation or calendars with the visit schedules or frequency of visits that we have given to the patients and families to keep in their blue binders in their homes, but we will start to do so."

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on document review and interview, the agency's Quality Assessment Performance Improvement program (QAPI) did not measure, analyze, or tack adverse patient events or demonstrate surveillance and investigation of infectious and communicable disease. The failure to track, trend, or analyze adverse events including the prevalence of patient infections had the potential for the HHA to miss opportunities to improve patient outcomes for all of 32 current patients receiving home care services. Review of documentation titled, "QAPI Meeting" dated 08/18/22 and 11/08/22 presented by the Director of Nursing (DON) as evidence of the HHA QAPI program failed to show evidence of tracking, trending, or analysis of patient adverse events which could include falls, rehospitalizations, and infections. Review of the agency’s policy's addressing QAPI revealed none of the policies presented addressed the inclusion of adverse patient events and infection tracking in QAPI. During an interview on 11/28/22 at 1:30 PM, the DON confirmed that the HHA QAPI documentation did not include tracking, trending, or analysis of patient adverse events including falls, rehospitalization, or infections. The DON stated it was possible to pull data from the electronic medical record although this had not been done or analyzed or brought to QAPI meetings.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on record review, observation, and interview, the agency failed to maintain an effective infection control program. The HHA failed to ensure staff followed standard precaution protocols, failed to track and analyze infection data, and failed to fully develop a Corona Virus Disease (COVID) vaccination policy per the Center for Medicare and Medicaid Services (CMS) QSO-23-02-HHA to include additional precautions for staff who have not been fully vaccinated to mitigate the transmission and spread of COVID-19. These failures had the potential to increase the prevalence of infection and communicable disease among all of its 32 current patients and all staff. 1. During a patient home visit a staff person was observed not following accepted standard infection control precautions. (Refer to G682) 2. The HHA did not have documentation to demonstrate an agency-wide program for infection surveillance, tracking, trending, investigation, or analysis. (Refer to G684) 3. The HHA did not fully develop its COVID-19 Vaccination policy per the CMS directive outlined in QSO-23-02 "Revised Guidance for Staff Vaccination Requirements" nor did its policy identify approaches for unvaccinated staff to mitigate the potential spread of COVID-19. (Refer to G687)

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 observation, staff interviews, and review of agency policies and procedures, the agency failed to ensure a Home Health Aide (HHA) performed appropriate hand hygiene when providing care in the home to one of one patient (Patient (P) 2). The HHA failed to ensure medical equipment such as pulse oximeter, blood pressure cuff, and digital thermometer were properly wiped down with alcohol wipes after each use. The HHA failed to ensure infection control techniques were performed to include placing a barrier down to put medical supplies on to prevent the spread of infection. The HHA placed the medical equipment on the patient's bed with no barrier. Failure to maintain proper infection control techniques during care could lead to infections for all 32 patients receiving care from this agency. During the entrance conference interview with the Director of Nursing (DON) on 11/28/22 at 9:00 AM, the DON stated that the agency "Is requiring all staff to wear surgical grade masks when in the patients home." Prior to conducting a home visit to P2's home on 11/28/22 at 2:45 PM, the Home Health Aide (HHA) was observed not wearing a surgical grade mask. During an interview, the HHA stated, "I don't normally wear a mask. I just ask the patient how they are feeling prior to going out to the home." When the HHA was asked how often she conducts visits to P2's home, the HHA stated, "Twice a week, I help with bathing, putting on clothes, combing hair, help getting dressed and do my vitals." The HHA stated that today was going to be her only visit with patient. During a home visit to P2's home on 11/28/22 from 3:00 PM to 3:45 PM, the HHA was observed entering P2's home wearing no mask. After entering P2's home, the HHA was observed to have a blue duffle bag of medical supplies. When meeting with P2 in P2's bedroom, the HHA proceed to place her blue duffle bag on the floor. There was no barrier that was placed on the floor prior to placing the bag down. The HHA proceeded to take out supplies to include a pulse oximeter (a device that is usually placed on a fingertip which uses light beams to estimate the oxygen saturation of the blood and pulse rate), digital thermometer, and blood pressure cuff in a container. The HHA placed all these items directly on P2's bed with no barrier placed down between P2's bed and supplies. After doing this, the HHA did not use any hand sanitizer and proceeded to pick up the pulse oximeter off P2's bed and said to P2, "let me take your vitals" and placed it directly on P2's right hand index finger. The HHA did not wipe the pulse oximeter down prior to placing it on P2's finger. The HHA did not use any hand sanitizer, then proceeded to pick up the digital thermometer off P2's bed and placed it close to P2's head for a temperature reading. The HHA was observed wiping the digital thermometer with an alcohol wipe, then placing it directly back on P2's bed. The HHA then was observed taking the pulse oximeter off the patient's right index finger and did not wipe it before the HHA placed it directly back on P2's bed. The HHA was observed not using any hand sanitizer after touching the pulse oximeter, digital thermometer, or after placing them directly on the patient's bed. The HHA was then observed picking up the white plastic blood pressure cuff container off P2's bed. The HHA did not clean or wipe off the container. The HHA took the blood pressure cuff out of the white container and then placed the blood pressure cuff and container directly on P2's bed. The HHA did not wipe off the blood pressure cuff. The HHA then sat directly on P2's bed with no barrier placed and proceeded to ask the patient questions. The HHA duffle bag was still observed sitting directly on the patient's bedroom floor with no barrier. The pulse oximeter, digital thermometer and blood pressure cuff and white container were still all laying on P2's bed with no barrier. The HHA was observed picking the blood pressure cuff off P2's bed with her unsanitized hands and placed it on P2's left wrist. Prior to doing so, the HHA did not wipe down the blood pressure cuff before placing it on P2's left wrist. After the blood pressure was taken, the HHA was then observed not sanitizing her hands, and proceeded to take off the blood pressure cuff from P2'sleft wrist and placed it directly back on the patient's bed. Due to a low blood pressure reading the HHA stated she would call the nurse to let the nurse know of the low reading. The HHA then used her cell phone to call the nurse. While on the phone with the nurse, the HHA picked up the blood pressure cuff off P2's bed, did not wipe it off, or sanitizer her hands. The HHA then placed the blood pressure cuff back on P2's left wrist to get a reading. After doing so, the HHA took off the blood pressure cuff and placed it directly back on P2's bed. The HHA did not wipe it off and did not use any hand sanitizer. The HHA then sat back on P2's bed and stated she would be getting the patient ready for her shower. During an interview with the HHA on 11/28/22 at 3:30 PM, the HHA was asked about hand hygiene, using any type of barrier to place her bag, and wiping off the medical supplies the HHA stated, "I usually put down a chux pad (a type of bed pad that protects beds and other surfaces from bodily fluids and can be tossed after each use) or a barrier. I should have put some type of barrier down." The HHA then stated, "I should have wiped down the equipment after using them on her and touching it with my hands, but I didn't." During an interview with the DON on 11/28/22 at 4:35 PM, regarding the above observation of the HHA, the DON stated, "All of our staff have their own equipment, and they are all expected to wipe down all their equipment prior to each use, and definitely after. If we have a COVID + patient, then we have extra disposable equipment such as blood pressure cuffs, stethoscopes, that would be left in the home." The DON stated, "If not a COVID + patient, then the staff are to wipe down their equipment to include pulse oximetry, thermometers, blood pressure cuffs, and stethoscopes before each use with alcohol wipes, or Clorox wipes and after each use. They are required to put a barrier down under their bags, and under all equipment such as a chux. My expectation is that they provide a clean bag technique by putting everything on the chux barrier because we don't know where their bags have been. They can get those here at the office whenever needed. We have plenty of supplies here." The DON stated, "They are to make sure they clean each piece of equipment with an alcohol wipe, or Clorox wipe in between each use, after each use, and then use hand sanitizer before going in the home and after use of equipment and touching the patient." When the DON was asked about the use of staff wearing surgical grade masks when providing care in the home, the DON stated, "When staff are out doing home visits, yes, they are required to be wearing a mask." When the DON was informed of the observations of the HHA during the home visit wearing no surgical mask, the DON stated, "There was no reason why the HHA didn't have any chux available to use and she should have wiped down her equipment before and after each use." During a second interview with the DON on 11/29/22 at 9:00 AM, regarding the use of personal protective equipment (PPE) for staff to use when providing care in patients home, the DON again stated, "We are requiring staff to wear surgical grade masks for a visit in the home. We have a whole stock of N95 masks, surgical grade masks, shields, gloves available to staff to get. There would be no reason why a staff member should not have these available to them." Review of the agency policy and procedure titled, "Infection Control and Maintenance of Environment/Equipment," last reviewed on 08/2021, revealed, “Policy: Agency employees implement infection control and maintenance procedures for environment and equipment, as appropriate…Procedures: 2. Client and employee infection control procedures include but are not limited to the following: a. Frequent hand washing by employees before and after direct client care. 3. Environment and equipment infection control procedures include but are not limited to the following: a. Maintaining a clean work area…J. Keeping the client environment clean, neat, and orderly." Review of the agency policy and procedure titled, "Universal Precautions," last reviewed on 08/2021, revealed, “Policy: Staff members employed by the Agency will practice Universal Precautions….Purpose: 1. To protect staff members and clients/patients from transmission of communicable disease. 2. To control spread of infection… Procedure: 2. All agency staff members will practice Universal Precautions. 3. "Universal Precautions include, but are not limited to a. Frequent handwashing or use of alcohol-based hand sanitizer by staff before and after direct patient contact…" Review of the agency policy and procedure titled, "Hand Washing," last reviewed 08/2021, revealed, “Policy: Employees will observe proper hand washing techniques at the proper times. Procedure: When to Wash Hands- 1. Before and After Client contact…5. When in doubt." Miscellaneous: "May use an antiseptic solution such as an alcohol-based hand sanitizer between tasks that would normally require hand washing…" Review of the undated agency policy and procedure titled, "Using Masks," revealed, “Policy: To prevent transmission of infectious agents through the air... Procedure: When to Use a Mask: When providing treatment or services to a patient and the use of a mask is indicated…Miscellaneous:1. Put mask on before entering the room. Be sure that hands are clean before putting on a facemask. 2. Be sure that facemask covers the nose and mouth while performing treatment or services for the patient…"

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on document review and interview, the agency failed to develop and maintain a systematic program for the surveillance of infection data or include this information as a part of its Quality Assessment Performance Improvement (QAPI) program in order to identify trends and possible causative factors. The failure to track and review the infection data had the potential to affect the care and services of all the home health patients receiving services. Review of all of the home health agency policies related to infection prevention and control revealed the agency did not have any policy that addressed the tracking, trending, and analysis of infection data. Review of the QAPI meeting minutes dated 08/18/22 and 11/08/22 revealed infection surveillance was not addressed. During an interview on 11/28/22 at 1:30 PM, the Director of Nursing (DON) confirmed that the HHA does not track, trend, or analyze infection control data and that the agency does not have a policy that addresses infection surveillance. He/she stated the data can be obtained from the electronic medical record (EMR), but the agency has not been doing this.

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 policy review and interview, the agency failed to ensure the agency's Corona Virus Disease (COVID) -19 vaccination policy contained all the required content identified in the Center for Medicare and Medicaid Services (CMS) memo QSO-23-02-ALL "Revised Guidance for Staff Vaccination Requirements" dated 10/26/22. The failure to fully develop a policy had the potential to affect all 32 current patients admitted to the home health agency (HHA) for services and all of the staff who provide services. Review of the agency policy titled, "COVID-19 Vaccination of Staff," dated 01/06/22, revealed, "Unless approved for a medical or religious exemption, all employees must be fully vaccinated against COVID-19 … Guidelines for vaccination will be based on hire date … Any person hired on or after February 28th must be fully vaccinated prior to being assigned an orientation date … A copy of the approved vaccination record will be made by CHC [Community Healthcare] and filed within the employee's medical file." The policy failed to include the following required elements: 1. 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 2. 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 (1) 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. 3. 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. 4. Contingency plans for staff who are not fully vaccinated for COVID-19. Review of an internal agency memo titled, "Update on weekly testing," revealed, "The decision has been made effective today 9/6/2022, CHC [Community Healthcare] will no longer require weekly testing for Caregivers who are on an exemption … Masks are no longer required while on your shift unless you are exposed." Review of staff COVID-19 testing documentation showed 100 percent compliance with the requirements for individual staff testing. Review of employee vaccination records revealed a total of fourteen staff. Twelve staff had been vaccinated and two staff had approved nonmedical exemptions. During an interview on 11/28/22 at 3:30 PM, the Director of Nursing (DON) confirmed this was the only agency policy related to COVID-19 vaccinations and that staff who have approved exemptions do not have to do anything specific to mitigate the potential spread of COVID-19. During an interview on 11/29/22 at 2:00 PM, Licensed Practical Nurse (LPN) confirmed he/she has a religious exemption. LPN stated he/she was not told of any additional precautions to implement to mitigate the potential spread of COVID-19

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 record reviews, and interviews, the agency failed to ensure the frequency of skilled services were being done as per physician orders in the plan of care for two of seven patients (Patients (P) 1 and P6). By not ensuring the frequency of skilled services are being conducted as ordered, there is a potential of negative outcomes and inconsistent care being provided to patients receiving services from this agency. 1.During an interview on 11/28/22 at 12:00 PM, the Registered Nurse (RN) stated that he has been seeing P1for skilled nursing visits three times a week on Monday, Wednesdays, and Fridays. Review of the "Oasis [Outcome and Assessment Information Set/the standardized assessment tool used for home health agency admissions]-D1 SOC [Start of Care]" located in the Electronic Medical Record (EMR) for P1, dated 10/05/22, indicated P1's start of care began on 10/05/22. The Oasis indicated under the "Orders for Discipline and Treatment" section that Skilled Nursing was ordered for 3x/week (three times a week) for 8 weeks. Review of the "Physician Frequency Orders" located in the EMR dated 10/05/22 indicated, "Orders: Skilled Nurse Frequency: 3x/week for assessment and wound care." Review of a "Home Health Certification and Plan of Care" located in the EMR dated 10/05/22 indicated, P1 would be receiving Skilled Nursing 3x/week for 8 weeks. Review of the "Calendar of Visits" located in the EMR indicated skilled nursing services were not being provided as ordered for 3x/week for P1. The calendar revealed the following inconsistencies: Only one visit completed on 10/05/22. Three visits completed on 10/09/22, 10/12/22, and 10/14/22. Two visits completed on 10/17/22 and on 10/19/22. Three visits completed on 10/24/22, 10/26/22, and on 10/28/22. Two visits completed on 11/02/22 and 11/04/22. Three visits completed on 11/07/22, 11/09/22, and on 11/11/22. Two visits completed on 11/15/22 and 11/17/22. Two visits completed on 11/21/22 and on 11/23/22. Further review of the calendar revealed no documentation of why visits were not being provided three times a week as ordered, or a reason for any missed visits. During an interview on 11/29/22 at 8:55 AM, regarding the frequency of visits ordered for skilled nursing services, the Director of Nursing (DON) stated, "I know we have issues with inconsistencies of visits. I know we are not following up as we should be. The nurse should be telling me why there is a missed visit and why only some weeks we are going twice a week instead of the ordered three times a week. They should have put a communication note in the EMR as to why there was only one visit, or two visits instead of three." When the DON was asked if she was aware that P1 was not receiving the skilled visits as ordered, the DON stated, "I think she [P1] may have cancelled a few times, but we don't have any documentation to show that. " When the DON was asked if the nurses were communicating with her about the inconsistency in skilled visits for P1, the DON stated, "I've told them if a patient cancels a visit, then they are supposed to write a communication note of the missed visit in the chart, then should be following up with me. I've identified some areas of concern where our staff are not communicating with me when there is missed visit." 2.Review P6's "Home Health Certification and Plan of Care" located in the "Orders" tab of the EMR with a certification period of 07/28/22 to 09/25/22 signed by the attending physician revealed the skilled nursing frequency ordered as "3W8 [three times a week for eight weeks] for wound care and one time for admission." Review of the skilled nursing visit notes located in the "Nursing" tab of the EMR revealed the actual nursing frequency as: one time a week times one (admission), two times a week times for one week(08/01/22, 08/05/22), three times a week for one week 08/08/22, 08/10/22, 08/12/22), two times a week for one week (08/16/22, 08/18/22), three times a week for one week (08/22/22, 08/24/22), two times a week for two weeks (08/29/22, 09/02/22, 09/07/22, 09/09/22), three times a week for one week(09/12/22, 09/14/22, 09/16/22), and two times a week for one week (09/19/22, 09/23/22). Review of visit notes in the "Nursing" tab and communication notes in the "Comm" tab failed to indicate why the visit frequency was different than the signed physician orders. Review of the "Orders" tab, "Comm [Communication]," and "Misc. [Miscellaneous]" tab failed to show that a visit frequency order change was received from the physician or that the physician was notified of missed visits.