Every finding on record at Corlan Home Health, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 03/21/24. Standard level deficiencies cited.

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 the review of the Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to conduct required testing of the Emergency Preparedness Plan. This has the potential to affect all patients who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 03/20/24 at 10:00 AM. The Emergency Preparedness plan lacked documentation that the Agency conducted / participated in any community-based testing exercises, since 2021. 2. The findings were confirmed during the interview, with the Administrator on 03/21/24 between 9:30 AM and 10:00 AM.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 03/21/24. Standard level deficiencies cited. Abbreviations: Pt./Pts. = patient/patients

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder and staff interviews, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) the Agency failed to provide information regarding the Clinical Manager (Director of Nursing) and their contact information. Findings include: 1. The Agency Pt. admission folder was reviewed on 03/18/24. The folder lacked information identifying the Clinical Manager's name and contact information. 2. The clinical records of the following Pts. were reviewed from 03/18/24 to 03/20/24. Pt. #1. SOC 02/22/23. Pt. #2. SOC 02/13/23. Pt. #3. SOC 02/19/24. Pt. #4. SOC 02/15/24. Pt. #5. SOC 02/21/22. Pt. #6. SOC 08/18/23. Pt. #7. SOC 12/29/23. The clinical records reviewed lacked information identifying the Clinical Manager's name and contact information. 3. The following home visits were conducted from 03/19/24 to 03/20/24 at 1:00 PM Pt. #1. SOC 02/22/23. Pt. #2. SOC 02/13/23. Pt. #3. SOC 02/19/24. 4. During the home visits, on 03/18/24 and 03/19/24 the Pt. admission folders were reviewed. The folders lacked the name and contact information of the Clinical Manager. 5. During staff interview with the Administrator and Clinical Manager (Director of Nursing) on 03/21/24 at 09:30 AM and 10:30 AM, it was indicated the same admission folder is given to all Patients. The administrative staff also confirmed the above findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on the clinical record review and Staff interviews, it was determined the Agency failed to complete the transfer-discharge summary for 1 of 2 (Pt.#6) discharged patients. Findings include: 1. Patient #6 was admitted to the Home Health Agency on 08/18/23 with the Diagnosis of Pressure Ulcer of Right Buttock Stage 2. The clinical record was reviewed on 03/19/24 and included a transfer-discharge summary dated 10/06/2024. The summary included the patient's name, date of birth, medical record number and start of care date. The summary lacked any other patient specific information. The summary was incomplete. 2. The above findings were confirmed with the Agency Supervisor and Administrator on 03/21/24 between 9:30 AM and 10:15 AM.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. *[For LTC facilities at §483.73(a)(1):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a)(1):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a)(2):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. This STANDARD is not met as evidenced by: . A. Based on review of Agency's Emergency Preparedness Binder review, Agency's Inservice Binder review and staff interview, it was determined that the Agency failed to ensure the Emergency Preparedness Plan was based on a facility and community risk assessment, utilizing an all hazards approach. Findings include: 1. The Agency's Emergency Preparedness Binder review and Agency's Inservice Binder were reviewed on 4/14/21 at 3:00 PM. The plan lacked documentation that a facility-based and/or community-based risk assessment was completed. 2. During an interview with the Administrator on 4/15/21 at 1:00 PM, the Administrator confirmed the above findings.

EP Testing Requirements CFR(s): 484.102(d)(2) *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d) (2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. This STANDARD is not met as evidenced by: . A. Based on review of Agency's Emergency Preparedness Binder review, Agency Inservice Binder review and staff interview, it was determined that the Agency failed to ensure testing of the Emergency Preparedness Plan was conducted. Findings include: 1. The Agency's Emergency Preparedness Binder and Agency Inservice Binder were reviewed on 4/14/21 at 3:00 PM. The plan lacked documentation to indicate that testing of Emergency Preparedness plan was conducted after 2018. 2. During an interview with the Administrator on 4/15/21 at 1:00 PM, the Administrator confirmed the above findings.

Recertification survey completed. Standard level deficiencies cited. A Focused Infection Control Survey (FIC) was conducted on 4/16/21. Corlan Home Health, Inc. was in compliance with the requirements for Infection Control for COVID-19. Abbreviations: x = times wk = week # = number AM = morning PO = by mouth PRN = as needed SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care MD = Medical Doctor RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients OASIS = Outcome and Assessment Information Set

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: . A. Based on the review of clinical records and staff interview, it was determined that the Agency failed to ensure that Pt had the right to participate in, be informed about and provide consent for care, as & when appropriate. This was found in 2 out of 2 discharged records. Findings include: 1. Pt # 6 SOC 04/04/2018 Diagnosis: Essential Hypertension The clinical record was reviewed on 04/15/21 at 12:30 PM. The record lacked 'Advance directive'. The 'Discharge OASIS' was not signed and dated. 2. Pt # 7 SOC 04/30/2019 Diagnosis: Unspecified Intestinal Obstruction The clinical record was reviewed on 04/15/21 at 10:00 AM. The record lacked any admission documents like 'Informed Consent for Admission', 'Beneficiary Election', 'Advance Directive' etc... 3. During an interview with the Agency Administrator and the Agency Supervisor on 04/15/21 at 02:00 PM, the Administrator stated that it is their practice to have Pts sign 'Consent for admission', 'Beneficiary Election', 'Advance Directives' and all other required documents for admission, prior to or during the admission process. The above findings were confirmed by them.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: . A. Based on observation, clinical record review, policy review and staff interview, it was determined that Agency failed to review all the medications the patient is currently using in order to identify any noncompliance, ineffective or unnecessary drug therapy. This was identified in 4 out of 7 records reviewed. Findings include: 1. Pt # 3 SOC 08/16/2018 Diagnosis: Constipation unspecified Home visit made on 04/14/21, at about 11:00 AM. POC included Bisacodyl 5 mg PO daily and Colace 100 mg daily at bedtime. Observed that RN did not review Pt's medications, Pt did not have a physician ordered med list at home, Pt did not have Bisacodyl at home and the frequency for Colace on the med bottle at home was 'three times a day as needed' . Pt verbalized that he don't need Bisacodyl & that the doctor discontinued it during her visit couple months ago. Also that he has a BM every 2-3 days, without any meds. Clinical record reviewed for Pt # 3 on 04/14/21 at 9:30 AM. The record showed that Pt has pain at 4-5/10 through out the certification period of 02/1/21 to 04/01/21. The goals on the POC indicated that Pt's pain will be controlled at 0-2/10. No modification in medication orders was made to ensure reduction of pain. 2. Pt # 4 SOC 02/17/21 Diagnosis: Type 2 Diabetes Mellitus without complications The clinical record was reviewed on 04/14/21 at 01:30 PM. The record showed that Pt has pain at 4-6/10 through out the certification period of 02/17/21 to 04/017/21. The goals on the POC indicated that Pt's pain will be controlled at 0-2/10. No modification in medication orders was made to ensure reduction of pain. 3. Pt # 6 SOC 04/04/2018 Diagnosis: Essential Hypertension The clinical record was reviewed on 04/15/21 at 12:30 PM. The record showed that Pt has pain at 5/10 through out the certification period of 11/19/20 to 01/17/21. The goals on the POC indicated that Pt's pain will be controlled at 0-2/10. modification in medication orders was made to ensure reduction of pain. 4. Pt # 7 SOC 04/30/2019 Diagnosis: Unspecified Intestinal Obstruction The clinical record was reviewed on 04/15/21 at 10:00 AM. The record showed that Pt has pain at 6/10 through out the certification period of 08/22/20 to 10/20/20. The goals on the POC indicated that Pt's pain will be controlled at 0-2/10. No modification in medication orders was made to ensure reduction of pain. 5. Agency's policy on pain management was reviewed on 04/16/21 at around noon, which states that 'the plan will be reviewed and modified if Pt does not have pain relief'. 6. The findings regarding not reviewing meds to identify any noncompliance, ineffective or unnecessary drug therapy was confirmed during an interview with the Agency Administrator and the Agency Supervisor on 04/15/21 at 02:00 PM.

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: . A. Based on clinical record review, observation and staff interview, it was determined that Agency failed to ensure that services were provided as indicated on the POC. This was identified in 2 out of 4 active Pts records reviewed. Findings include: 1. Pt # 3 SOC 08/16/2018 Diagnosis: Constipation unspecified Clinical record reviewed on 04/14/21 at 9:30 AM. The treatment orders for the SN in the POC includes assessing Pt for pain, constipation, and fall prevention. Home visit made on 04/14/21, at about 11:00 AM. Observed that RN did not assess the Pt when was his last BM, his current pain level or assess Pt for ability to ambulate or safety measures. Pt verbalized that his WC has been broken for last 3 days and that he has difficulty to ambulate. On asking how he gets to the bathroom without the WC, he says,"I crawl to the bathroom & get myself onto the toilet...". 2. Pt # 4 SOC 02/17/21 Diagnosis: Type 2 Diabetes Mellitus without complications The clinical record was reviewed on 04/14/21 at 01:30 PM. The record showed that Pt's blood sugar was not recorded for week 7 (04/01/21) and week 8 (04/08/21). The orders for SN on the POC states that SN should monitor the blood sugar to maintain it within the range of 80-140mg/dl. 3. Pt # 7 SOC 04/30/2019 Diagnosis: Unspecified Intestinal Obstruction The clinical record was reviewed on 04/15/21 at 10:00 AM. The POC states that Pt has a functional limitation of dyspnea with moderate exertion and has a order to assess respiratory status and vital signs. There was no oxygen saturation recorded during any of the SN visits from week 3 to week 8 (9/3/20 to 10/8/20). 4. During an interview with the Agency Administrator and the Agency Supervisor on 04/15/21 at 02:00 PM, the Administrator and the DON stated that it is their practice to check oxygen saturation as part of vital signs for all Pts. The findings regarding Agency not ensuring that SN follows POC orders was confirmed by them.