Every finding on record at Crescent Home Health Agency, LLC

A partial extended survey for Medicare recertification for the home health provider was completed on 03/06/2024. The provider had 18 current patients. The Emergency Preparedness regulations were also reviewed as part of the Medicare recertification survey completed on 03/06/2024. One standard level deficiency was identified.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on policy review, employee record review and interview, the home health provider failed to ensure emergency preparedness (EP) training was completed on hire in four of four employee records reviewed (Employees #1, #2, #3, and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Job Description: Clinical Director,” showed the duties and responsibilities of the clinical manager included: - Provision and oversight of initial and ongoing in-service education and training for all nursing and home health aide staff; and - Assist the administrator in recruiting, interviewing, hiring and ensuring adequate orientation of all staff. EMPLOYEE #1: Review of Employee #1’s personnel file showed: - A hire date of 09/01/2023; - The employee’s position was licensed practical nurse; - Orientation in-service training took place on 09/01/2023; and - The personnel file failed to contain evidence that EP training was completed upon hire. EMPLOYEE #2: Review of Employee #2’s personnel file showed: - A hire date of 11/17/2023; - The employee’s position was office/intake; - Orientation in-service training took place on 11/1/2023; and - The personnel file failed to contain evidence that EP training was completed upon hire. EMPLOYEE #3: Review of Employee #3’s personnel file showed: - A hire date of 01/17/2023; - The employee was hired under arrangement and the position was physical therapy assistant; - Orientation in-service training took place on 01/17/2023; and - The file failed to contain evidence that EP training was completed upon hire. EMPLOYEE #4: Review of Employee #4’s personnel file showed: - A hire date of 12/06/2022; - The employee’s position was office/intake; - Orientation in-service training took place on 12/07/2022; and - The file failed to contain evidence that EP training was completed upon hire. During an interview on 03/05/2023 at 1:00 PM, the administrator stated that they do EP training as a group and there should be a roster of employees who attended. He/she went into the office and looked for the information but returned without any documentation to show EP training was completed, at any time, by Employees #1, #2, #3 and #4.

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 admission packet review, home visit observation, and interview, the provider failed to ensure the right to be informed of the state toll-free home health telephone hotline number hours of operation in three of three home visit observations (Records/Patients #1, #2, and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: The provider’s administrator furnished an admission packet for review on 03/04/2024.The provider’s notice of patient rights and other information given to a patient during the initial visit failed to show written information regarding the home health hotline hours of operation. RECORD/PATIENT #1: During a home visit observation on 03/04/2024 at 1:00 PM, review of the provider-furnished patient admission packet showed in part: - A document titled, “Your Rights and Responsibilities,” updated 2021; - The right to know the number of the home health hotline in your state; and - The patient admission packet failed to show the home health hotline hours of operation. RECORD/PATIENT #2: During a home visit observation on 03/04/2024 at 2:00 PM, review of the provider-furnished patient admission packet showed: - A document titled, “Your Rights and Responsibilities,” updated 2021; - The right to know the number of the home health hotline in your state; and - The patient admission packet failed to show the home health hotline hours of operation. RECORD/PATIENT #4 During a home visit observation on 03/05/2024 at 11:00 AM, review of the provider-furnished patient admission packet showed: - - A document titled, “Your Rights and Responsibilities,” updated 2021; - The right to know the number of the home health hotline in your state; and - The patient admission packet failed to show the home health hotline hours of operation. During an interview on 03/06/2024 at 11:00 AM, the administrator stated that the staff had failed to include this information in the patient admission packets when printing the patient rights policies portion in all the current patient admission packets.

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: Based on policy review, record review, observation and interview, the home health provider failed to ensure staff maintained an accurate and updated medication profile in, but not limited to, one of three home visit observations (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Profile,” dated 01/31/2014, showed in part: - Upon admission the admitting clinician will initiate a medication sheet documenting all current medications being taken by the patient including dosage, route and frequency and reconcile all medication lists that may be present at the time of admission and all medications that are found in the home; - Any discrepancies must be resolved; and - Medication records will be updated with each change in medication dose or frequency, as well as the addition or discontinuation of medication. RECORD/PATIENT #1: Observation and interview on 03/04/2024 at 1:00 PM, during the patient’s home visit, showed the following discrepancies with the medication in the patient’s home and the provider’s medication profile: - The provider’s medication profile showed an order for tizanidine (a muscle relaxer) 4 milligrams (mg) one capsule at bedtime. The patient stated that he/she had not taken it for six months; - The provider’s medication profile showed an order for hydralazine (for high blood pressure) 25 mg take one tab daily. The patient stated that he/she was no longer taking the medication; - The provider’s medication profile showed an order for acetaminophen 325 mg take two tablets every six hours as needed (PRN) for pain. The patient was taking extra strength acetaminophen 500 mg two tablets every six hours PRN; and - The patient had a bottle of docusate sodium (a stool softener) 100 mg take one to two gel capsules at bedtime PRN. The provider’s medication profile failed to contain this medication. During an interview immediately following the home visit, the clinical manager stated that they do not usually look at the medication bottles, they looked at the medication list with each visit and ask the patient if there were any medication changes. He/she was surprised when the patient informed them that they were no longer taking the hydralazine and the tizanidine because the patient had always denied changes when asked. During an interview on 03/06/2024, at 9:48 AM, the clinical manager stated that they do look at the medication bottles, the first time in the home when a patient is admitted but, after that, they look at the medication list. He/she stated that they needed to do more.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on policy review, record review and interview, the home health provider failed to notify the physician of blood pressures outside of ordered parameters in one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning,” dated June 2010, showed in part: - The plan of care (POC) is based upon the physician’s orders and encompasses the equipment, supplies and services required to meet the patient’s needs; and - Clinician’s will inform the patient’s physician of any changes which may indicate a need for a change in the plan of treatment. Review of the provider’s policy titled, “Physician Orders,” dated June 2010, showed “physician orders will be obtained when indicated by patient need or a change in the patient’s medical condition”. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 12/30/2023 with a diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient had additional diagnoses of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood), diabetes (a group of diseases that results in too much sugar in the blood), chronic kidney disease and an unspecified wound on the left lower leg. The patient was transferred to the hospital on 01/30/2024 with an exacerbation of COPD and acute respiratory failure and the provider resumed care on 02/04/2024. The patient lived alone with the assistance of paid caregivers and was dependent on continuous oxygen. Review of the POC, dated 02/28/2024, showed orders to notify the physician of a systolic blood pressure greater than 180 or less than 100 and a diastolic blood pressure greater than 90 or less than 60. Review of physical therapy notes showed the following: - On 01/12/2024 the patient’s blood pressure was 108/45 (diastolic less than 60) and the clinician failed to notify the physician; - On 01/18/2024 the patient’s blood pressure was 133/56 (diastolic less than 60) and the clinician failed to notify the physician; - On 02/06/2024 the patient’s blood pressure was 139/51 (diastolic less than 60) and the clinician failed to notify the physician; - On 02/08/2024 the patient’s blood pressure was 125/53 (diastolic less than 60) and the clinician failed to notify the physician; and - On 02/13/2024 the patient’s blood pressure was 117/50 (diastolic less than 60) and the clinician failed to notify the physician. During and interview on 03/06/2024 at 9:48 AM, the clinical manager stated that he/she would expect the clinician to notify the physician if the blood pressures were outside of the ordered parameters.

Other pertinent instructions CFR(s): 484.60(e)(4) Any other pertinent instruction related to the patient's care and treatments that the HHA will provide, specific to the patient's care needs. This ELEMENT is not met as evidenced by: Based on policy review, record review, observation and interview, the home health provider failed to provide the patient with written instructions to report vital signs outside of parameters, measures to alleviate edema (swelling), monitor an area of skin concern on the left lower extremity for deterioration, dietary/fluid restrictions and the importance of self-monitoring for weight gain in one of three home visit observations conducted (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Patient Bill of Rights and Responsibilities,” dated 06/2010, showed in support of the home care service’s philosophy of care, each patient is an active, informed participant in his/her plan of care. To ensure this process, the patient must be empowered with certain rights and responsibilities. Every patient receiving service shall, upon admission, be provided with and have explained, the patient bill of rights and responsibilities on or before admission to service. The patient is informed of the right to participate in all aspects of care/service on admission. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 12/30/2023 with a diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). The patient had additional diagnoses of congestive heart failure (CHF; a decrease in the ability of the heart to pump blood), diabetes (a group of diseases that results in too much sugar in the blood), chronic kidney disease and an unspecified wound on the left lower leg. The patient was transferred to the hospital on 01/30/2024 with an exacerbation of COPD and acute respiratory failure and the provider resumed care on 02/04/2024. The patient lived alone with the assistance of paid caregivers and was dependent on continuous oxygen. Review of the plan of care (POC), dated 02/28/2024, showed in part: - The patient was to follow a low sodium, no added salt, heart healthy diabetic diet with a 1500 milliliter per 24-hour fluid restriction; - The patient had a four centimeter (cm) by four cm area of concern that was “not open yet but will open if (his/her) edema continues. It is blue and purple in colour (color). Pts (patient’s) both legs and feet have 3 (three) plus edema”; - Skilled nurse (SN) to visit one time a week for eight weeks; - SN to instruct on pursed lip breathing techniques, controlling stress, conservation of energy, and measures to alleviate edema; - The patient/caregiver was to apply barrier cream to buttocks and skin folds after every bowel movement; and - The patient was to monitor weight daily and report to SN any weight gain of two to three pounds in one day or five to seven pounds in one week. Observation on 03/04/2024 at 1:00 PM, during the patient’s home visit, showed the registered nurse (RN) assessed and provided education to the patient and the paid caregiver regarding elevation of lower extremities to decrease edema in the lower extremities, the importance of position changes (patient was sitting in his/her wheelchair with feet dangling since getting out of bed that morning) to a recliner so pressure was relieved from buttocks and so the lower extremities could be elevated. Techniques to manage periods of shortness of breath and anxiety (instructed on pursed lip breathing) and daily weights to monitor for weight gain (the patient had two digital scales, neither were working properly when the nurse attempted to weigh the patient, the patient stated that the batteries were dead) The caregiver stated that it was only his/her first day and he/she was trying to learn what the patient’s needs were. When the RN instructed the caregiver, the patient interrupted and requested that the RN speak directly to him/her and not to the caregiver. Review of the admission folder provided to the patient from the home health showed the provider failed to contain a copy of written instructions related to the patient’s specific care needs. During an interview immediately following the home visit, the paid caregiver stated that he/she was trying to learn what the patient’s needs were and was trying to encourage the patient to follow the recommendations of the home health nurse, but the patient could be difficult, and he/she expected the caregiver to know everything that was supposed to be done on their first day. During an interview on 03/06/2024 at 9:48 AM, the clinical manager stated that the patient probably wouldn’t remember all the teaching and instructions discussed during the visit and agreed the patient should have written instructions.

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 policy review, observation and interview, the home health provider failed to furnish the patient and caregiver, in writing, with the name and contact information of the clinical manager in, but not limited to, one home visit observation conducted (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Job Description: Clinical Director,” showed in part, the following duties and responsibilities of the clinical manager: - Responsible for the overall supervision and direction of health care services; - Shares responsibilities with the administrator for the provider’s overall compliance with state and federal guidelines and standards of nursing practice; - Supervise and direct all clinical services; - Promote, review, and evaluate the quality and appropriateness of patient care practices; - Revise the nursing care plan for appropriateness and application of physician’s plan of care; - Maintain contact with patient and family; - Review patient care through on-going communication with staff; - Review and act to resolve complaints made by patients/families regarding care provided relating to services, personnel, or policies; - Receive and act to resolve complaints from caregivers regarding policies and procedures; - Coordinate individual cases to needed disciplines; and - Coordinate and ensure that the patient is well serviced through the assignment of skilled services and personal caregivers whose skills and abilities meet their individual needs. Observation on 03/04/2024 at 1:00 PM, during the patient’s home visit, showed the home health folder, furnished by the provider to the patient on admission, failed to include written information on the name and contact information for the clinical manager or an explanation regarding when the clinical manager should be contacted. During an interview on 03/06/2024, at 9:48 AM, the administrator stated that they added the name and contact information for the administrator and the clinical manager to the admission packets and were in the process of getting them to their current patients.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on policy review, employee record review, and interview, the home health provider failed to ensure infection control training was completed on hire and annually in three of four employee records reviewed (Employees #2, #3, and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Infection Control Program Outline,” showed the risk of development of a health care associated infection may be minimized through proactive activities including ongoing education to all agency staff, patients/families about infection prevention and control techniques/responsibilities. Review of the provider’s undated policy titled, “Job Description: Clinical Director,” showed the duties and responsibilities of the clinical manager included: - Provision and oversight of initial and ongoing in-service education and training for all nursing and home health aide staff; and - Assist the administrator in recruiting, interviewing, hiring and ensuring adequate orientation of all staff. EMPLOYEE #2: Review of Employee #2’s personnel file showed, in part: - A hire date of 11/17/2023; - The employee’s position was office/intake; - Orientation in-service training took place on 11/1/2023; and - The personnel file failed to contain evidence that infection control training was completed upon hire. EMPLOYEE #3: Review of Employee #3’s personnel file showed, in part: - A hire date of 01/17/2023; - The employee was hired under arrangement and the position was physical therapy assistant; - Orientation in-service training took place on 01/17/2023; - The file failed to contain evidence that infection control training was completed upon hire; and - The file failed to contain evidence that infection control training was completed annually. EMPLOYEE #4: Review of Employee #4’s personnel file showed, in part: - A hire date of 12/06/2022; - The employee’s position was office/intake; - Orientation in-service training took place on 12/07/2022; and - The file failed to contain evidence that infection control training was completed upon hire. During an interview on 03/05/2024 at 1:00 PM, the administrator and clinical manager both stated that they did not know the office workers had to do infection control training on hire and annually. No further information was offered for the missing training in the physical therapy assistant’s file.

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 policy review, record review and interview, the home health provider failed to assess the patient’s blood sugar every visit as ordered by the physician in one of five full records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning,” dated 06/2010, showed the plan of care is based upon the physician’s orders and encompasses the equipment, supplies and services required to meet the patient’s needs. Review of the provider’s policy titled, “Physician Orders,” dated 06/2010, showed all skilled services are provided under the direction of a physician. RECORD/PATIENT #5: Review of the clinical record showed the patient was hospitalized on 12/25/2023 with a myocardial infarction (heart attack) and was found to have sepsis (a life-threating infection in the blood stream) with diabetic ketoacidosis (DKA – a potentially life-threatening condition caused by severe high blood sugar). He/she was admitted to home health services on 01/02/2024 with a diagnosis of diabetes with hyperglycemia (a group of diseases that results in too much sugar in the blood). The patient lived in his/her own home and had a family member staying with him/her. Review of the plan of care (POC), dated 01/02/2024, showed in part: - Skilled nurse (SN) to assess blood sugar via finger stick every visit prior to insulin administration; - The patient is using an “arm devive (misspelled device) for BS (blood sugar) checks” (Free-Style Libre system); - Lantus insulin (long-acting insulin) 14 units at bedtime; and - Humalog insulin (short-acting insulin) 12 units with each meal. Review of the SN notes, showed in part: - On 01/19/2024, the SN failed to assess and record a blood sugar; - On 01/25/2024, the SN failed to assess and record a blood sugar; and - On 02/23/2024, the SN failed to assess and record a blood sugar. During an interview on 03/06/2024 at 9:56 AM, the clinical manager stated that he/she would have expected the clinician to have obtained a blood sugar reading at every visit as ordered by the physician.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on policy review, employee record review, and interview, the home health provider failed to ensure the Employee Disqualification List (EDL) was checked prior to hire on one of four employee files reviewed (Employee #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Selection of Personnel,” showed the prospective personnel will be subject to a “limited criminal history check within 3 (three) days of hire”. Review of the provider’s undated policy titled, “Job Description CEO/Administrator” showed the administrator’s summary of job functions include: - Ensure that policies and procedures meet federal, state, local, and accrediting organization regulations and standards; and - Comply with applicable laws and regulations. EMPLOYEE #2: Review of Employee #2’s personnel file showed: - A hire date of 11/17/2023; - The employee’s position was office/intake; and - The personnel file failed to contain evidence that the EDL was checked prior to hire. During an interview on 03/05/2024 at 1:00 PM, the chief financial officer stated that they check the EDL but do not print out the page to prove they checked it.

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 policy review, record review, and interview, the home health provider failed to ensure the patient’s discharge summary was sent to the patient’s physician within five business days of discharge in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect the continuum of care for all patients discharged by the provider. Findings included: Review of the provider’s policy titled, “Transfer and Discharge of Services,” dated 06/2010, showed: - When a patient is discharged, relevant information includes the reason for discharge, physical and psychosocial status at the time of discharge, summary of the care and service provided and progress toward achieving goals, instructions provided to the patient and a complete list of medications; - The date of discharge is the date the last visit was made; and - A copy will be forwarded to the attending physician at his/her request. RECORD/PATIENT #3: On survey entrance, the home health office staff provided a list of their current patients. Patient #3 was selected for the patient sample as a current patient. Review of the clinical record showed: - The patient was admitted on 01/11/2024 with a diagnosis of radiculopathy of the lumbar region (low back pain with radiation down the left leg); - The plan of care (POC) showed orders for physical therapy (PT) only, one visit a week for one week then two visits a week for four weeks; - The patient was discharged from PT on 02/08/2024 (the date of the last visit); - The patient was not discharged from the provider’s computer system and was still listed as a current patient; - A document titled “Task Details” that showed the discharge summary was faxed to the physician’s office on 03/06/2024 (18 business days after the patient’s discharge from services); - The provider failed to send the discharge summary to the patient’s physician within five business days of the discharge. During an interview on 03/06/2024 at 10:15 AM, the administrator produced a discharge summary that showed it was just faxed to the physician on 03/06/2024. The clinical manager stated that he/she saw the fax was dated for the current day and understood that it was well after the discharge date of 02/08/2024.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the home health provider failed to ensure the plan of care (POC) was signed and dated by the physical therapist (PT) in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: RECORD/PATIENT #3: Review of the clinical record showed in part: - A referral, dated 01/08/2024, for home health PT strengthening exercises; - A communication note to the physician, dated 01/10/2024, showed the patient refused the visit but was agreeable to being seen on 01/11/2024; - The initial assessment was signed as completed by the PT on 01/11/2024; - A communication note digitally signed by office staff, dated 03/04/2024, that showed “Clinician will upload the CMS 485 (Centers for Medicare Services 485 – POC) and DC (discharge) documents shortly”; - The POC, dated 01/11/2024, showed orders for PT to visit one time a week for the first week then two times a week for the next four weeks; - The POC showed a PT treatment plan for therapeutic exercises, establish or upgrade a home exercise program, transfer training, gait training, and assistive device training; - The POC showed the PT had established goals for the patient to be independent with the home exercise program in three weeks, a decrease in pain to two on a scale of zero to 10 in five weeks (using numerical pain scale, zero meaning no pain and 10 meaning worst possible pain), independent with transfers in three weeks, independent with gait in three weeks; and - The POC failed to show the signature and date of the PT who established the POC with the physician. During an interview on 03/06/2024 at 11:20 AM, the clinical manager stated that the expectation was for the initial assessment (OASIS – Outcome and Assessment Information Set) to be completed in five days but the clinicians should complete all other notes within the same day including the clinician’s signature and date.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: The Emergency Preparedness regulations were reviewed as part of the Medicare certification survey completed on 09/02/2021. One condition level deficiency was identified at 484.102 Condition of Participation: Emergency Preparedness for Home Health Agencies. The following standard level deficiencies were cited under this condition of participation: - The home health agency (HHA) must develop and maintain an emergency preparedness plan that must be reviewed and updated at least every two (2) years (E0004); - Include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation (E0009); - The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency (E0024); - The HHA must develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and must be reviewed and updated at least every two (2) years (E0029) - The plan must include names and contact information for staff, entities providing services under agreement, patient's physicians, and volunteers (E0030); - Contact information for Federal, State, tribal, regional, and local emergency preparedness staff and other sources of assistance (E0031); - Training program: The HHA must do all of the following: Provide training in emergency preparedness policies, and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles; provide emergency preparedness training at least every two (2) years; maintain documentation of the training; demonstrate staff knowledge of emergency procedures; and if the emergency policies and procedures are significantly updated, the HHA must conduct training on the updated policies and procedures; (E0037) - Testing: must include exercises to test the plan at least annually; the agency must provide * Documentation of most recent full-scale community based exercise or * Conduct an additional exercise every two (2) years opposite the year of one of the above exercises that may be any of the exercises required, mock disaster drill, or tabletop exercise; and * Provide the analysis /documentation of the agency's response to all drills, table top exercises and emergency events for the last two (2) years (E0039). The cumulative effect of this deficient practice has the potential to affect the quality of care and safety of all agency patients.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure they developed and maintained an Emergency Preparedness (EP) plan that was reviewed and updated at least annually based on a facility based and community based risk assessment utilizing an all hazards approach which contained all elements. This deficient practice has the potential to adversely affect the care and safety of all patients served by the agency during an emergency. Findings included: Review of the agency's undated policy titled "Emergency Disaster Preparedness Plan" showed: - All employees will be oriented to the EP disaster plan, including their responsibilities in carrying out the plan upon hire, and will participate in current agency plan in-service educational sessions annually; - Agency employees will actively participate in EP practice drills, both internal and community wide drills; and - The plan will be reviewed and updated, minimally, on annual basis. Review of the agency's Emergency Preparedness manual did not show when the manual/plan was initiated or last updated. Findings were reviewed with the administrator and the director of nursing/clinical manager on 08/31/2021 at 4:15 PM and no further information was provided. CHAPS (Community Health Accreditation Partners) had advised the agency of what was needed for the EP plan.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on review of the agency's Emergency Preparedness (EP) binder and interview, the agency failed to include a comprehensive process for cooperation and collaboration with local, regional, state and federal EP officials. This deficient practice has the potential to adversely affect the care and safety of all patients served by the agency during an emergency. Findings included: Review of the EP binder failed to show evidence of a comprehensive process to ensure cooperation and collaboration with local, regional, state, and federal EP officials. Findings were reviewed with the administrator and the director of nursing/clinical manager on 08/31/2021 at 4:15 PM and no further information was provided. CHAPS (Communnity Health Acceredidation Partners) had advised the agency of what was needed for the EP plan.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on observation and interview, the agency failed to ensure a policy for emergency staffing strategies was developed for the agency's Emergency Preparedness (EP) plan. This deficient practice has the potential to adversely affect the care and safety of all patients served by the agency during an emergency. Findings included: Review of the agency's EP binder did not have a policy for emergency staffing strategies or the use of volunteers during an emergency;including the process and role for integration of state and federally designated health care professionals to assist with needs during an emergency. Findings were reviewed with the administrator and the director of nursing/clinical manager on 08/31/2021 at 4:15 PM and no further information was provided. CHAPS (Community Health Accreditation Partners) had advised the agency of what was needed for the EP plan.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on review of the agency's Emergency Preparedness (EP) binder and interview, the agency failed to develop a comprehensive communication plan that included names and contact information of staff, physicians, and other service provider to be accessed during an emergency. This deficient practice has the potential to adversely affect the care and safety of all patients served by the agency during an emergency. Findings included: Review of the agency's EP binder did not show a comprehensive communication plan that included names and contact information of staff, physicians and other service providers to be accessed during an emergency. Findings were reviewed with the administrator and the director of nursing/clinical manager on 08/31/2021 at 4:15 PM and no further information was provided. CHAPS (Community Health Accreditation Partners) had advised the agency of what was needed for the EP plan.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on review the agency's Emergency Preparedness (EP) binder and interview, the agency failed to ensure names and contact information for staff, entities providing services under arrangement, patient's physicians, and volunteers was included in the EP plan. This deficient practice has the potential to adversely affect the care and safety of all patients served by the agency during an emergency. Findings included: Review of the agency's EP binder did not include names and contact information for staff, entities providing services under arrangement, patient's physicians, and volunteers. Findings were reviewed with the administrator and the director of nursing/clinical manager on 08/31/2021 at 4:15 PM and no further information was provided. CHAPS (Community Health Accreditation Partners) had advised the agency of what was needed for the EP plan.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on review of the agency's Emergency Preparedness (EP) binder and interview, the agency failed to ensure contact information was included and updated for federal, state, tribal, regional, or local emergency preparedness staff and other sources of assistance. This deficient practice has the potential to adversely affect the care and safety of all patients served by the agency during an emergency. Findings included: Review of the agency's EP binder showed no contact information for federal state, tribal, regional EP staff and no updated information for local EP staff or other sources of assistance. Findings were reviewed with the administrator and the director of nursing/clinical manager on 08/31/2021 at 4:15 PM and no further information was provided. CHAPS (Community Health Accreditation Partners) had advised the agency of what was needed for the EP plan.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure staff were provided annual Emergency Preparedness (EP) training in three (Employee #1, #2, and #4) of five employee files reviewed. This deficient practice has the potential to adversely affect the care and safety of all patients served by the agency during an emergency. Findings included: Review of the agency's undated policy titled "Emergency Disaster Preparedness Plan" showed: - All employees will be oriented to the EP disaster plan, including their responsibilities in carrying out the plan upon hire, and will participate in current agency plan in-service educational sessions annually. EMPLOYEE #1 (E1): - Date of hire: 06/13/2017; - Position: Licensed practical nurse (LPN); - No evidence of EP training on orientation and every two years. EMPLOYEE #2 (E2): - Date of hire: 06/15/2017; - Position: Master social worker (MSW); - No evidence of EP training on orientation and every two years. EMPLOYEE #4 (E4): - Date of hire: Contracted, 02/25/2021; - Position: Speech therapist (ST); - No evidence of EP training on orientation. During an interview on 09/02/2021 at 9:00 AM, the director of nursing/clinical manager stated that: - The agency provided EP training but not all attended the training.

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), §485.625(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, 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 review of the agency's Emergency Preparedness (EP) plan and interview, the agency failed to conduct exercises to test the emergency plan annually and analyze the agency's response to and maintain documentation of all drills, table top exercises, and emergency events, and revise the agency's emergency plan as needed. This deficient practice has the potential to adversely affect the care and safety of all patients served by the agency during an emergency. Findings included: Review of the agency's undated policy titled "Emergency Disaster Preparedness Plan" showed: - All employees will be oriented to the EP disaster plan, including their responsibilities in carrying out the plan upon hire, and will participate in current agency plan in-service educational sessions annually; - Agency employees will actively participate in EP practice drills, both internal and community wide drills; and - The plan will be reviewed and updated, minimally, on an annual basis. Review of the agency's EP binder failed to show documentation of: - Emergency drills or table top exercises in 2018 or 2019; -Community based exercises documented in 2018 or 2019; Review of the agency's EP binder showed: - COVID-19 conference call training on 03/12/2020 was cancelled by the presenters, so not able to attend; - Only provided in-service for COVID 19 for staff in July, 2020 and June, 2021; - Attempted to join the Coalition for EP on 02/05/2020; the drill was canceled on 03/10/2020; and - No other training or drills provided for staff.

An extended survey for Medicare certification for Crescent Home Health Agency, LLC was completed on 09/02/2021. The agency had 20 current patients. Five condition level deficiencies were identified during this survey. A condition level deficiency is identified at: - 484.30 Condition of Participation: Care Planning, coordinating of services, and quality of care; * G570, G574, G580, G608, G610. G614, G616, G618 and G622; - 484.50 Condition of Participation: Patient Rights * G406, G412, G414, G422, G430, G432, G434, G436, G440, G442, G444, G446, G450, G452, G454, G456, G458, G460, G462, G464, G470, G472, G474, and G490; - 484.65 Condition of Participation: Quality assessment and performance improvement QAPI): * G640; and - 484.105 Condition of Participation: Organization and administration of services * G940, G948, G958, and G968. The Emergency Preparedness regulations were also reviewed as part of the Medicare certification survey completed on 09/02/2021 and deficiency citations included a condition level deficiency identified at - 484.102 Condition of Participation: Emergency Preparedness *E0001, E0004, E0009, E0024, E0029, E0030, E0031, E0037, and E0039. A home health agency that is found out of compliance with any Condition of Participation evaluated as part of a standard survey may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. A deficiency has been cited at §484.80(f)(3) - see Tag G788. A COVID-19 Focused Infection Control Survey was completed in conjunction with the survey and deficiencies were identified related to the Focused Infection Control Survey.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on policy review, current patient rights information, clinical record review, observation, and interview, the agency failed to develop and provide the patient and/or representative with a written notice of patient rights that included all required information. The agency failed to provide in writing, in advance of furnishing care, the following information: - Written notice of the patient's rights and responsibilities under this rule, and the agency transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities (G412); - The contact information for the home health agency's current administrator, including the name of the administrator (G414); - Provide written notice of the patient's rights and responsibilities, under this rule and the agency transfer and discharge policies to a patient-selected representative within 4 business days of the initial evaluation visit (G422); - The patient has the right to be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property (G430); - The patient has the right to make complaints to the agency regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the agency (G432); - The patient has the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to: * The completion of all assessments; and * The care to be furnished, based on the comprehensive assessment (G434); - Receive all services as outlined in the plan of care (G436); - The patient has the right to be advised orally and in writing of the extent to which payment for home health agency services may be expected from Medicare, Medicaid, or any other Federally funded or Federal aid program known to the home health agency, any changes in the financial information provided in accordance with paragraph (c)(7) of this section when they occur, the agency must advise the patient and representative of these changes as soon as possible, in advance of the next home health visit, the agency must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f) (G440); - The patient has the right to receive proper written notice, in advance of a specific service being furnished if the agency believes that the service may be non-covered care; or in advance of the home health agency reducing or terminating on-going care (G442); - Be advised of the state toll free home health telephone hotline, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local home health agencies (G444); - Be advised of the names, addresses, and telephone numbers of the federally-funded and state-funded entities that serve the area where the patient resides that include: Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center, and the Quality Improvement Organization of Livanta LLC (G446); -The patient has the right to be informed of the right to access auxiliary aids and language services as described in paragraph (f) of the section, and how to access these services (G450); - The patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge as follows: * The transfer or discharge is necessary for the patient's welfare because the HHA and the physician who is responsible for the home health plan of care that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities (G454); * The patient or payer will no longer pay for the services (G456); * The physician and agency agree that the outcomes and goals have been achieved and the patient no longer needs the agency services (G458); * The patient refuses services or elects to be transferred or discharged (G460); * The agency determines that the patients or other persons in the home, behavior is disruptive, abusive or uncooperative to extent that the delivery of care to the patient or the ability of the agency to operate effectively is impaired (G462); * The agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, that a discharge for cause is being considered (G464); * The agency must document the problem and efforts made to resolve the problem (G470); * The patient dies (G472); * The agency ceases to operate (G474); and - Information must be provided to patients in a language and in a manner that is accessible and timely to: * Persons with disabilities, including accessible web sites and the provision of auxiliary aide services and at no cost to the individual; and * Must be provided to persons with limited English proficiency, at no cost to the individual including oral interpretation and written translations (G490). The cumulative effect of these deficient practices resulted in the agency's inability to ensure that all patients and/or representatives were informed of their rights and responsibilities.

Written notice of patient's rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient's rights and responsibilities under this rule, and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to include: - Transfer and discharge policies; - Rights and responsibilities that are understandable to persons who have limited English proficiency; and - Rights and responsibilities accessible to individuals with disabilities. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 showed, in part: - Each patient is an active, informed participant in his/her plan of care; - Every patient receiving service from the agency shall, upon admission, be provided with and have explained, the patient bill of rights and responsibilities including HIPAA and Oasis privacy acts. Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," showed, in part: - The right to have your or your family's complaints heard, reviewed and if possible resolved concerning care that is or should have been furnished; - Have the right to know about the results of such complaints; - Our complaint resolution process regarding care, services or a lack of respect for property is explained; - The agency failed to include notice with respect to completion of all assessments, care to be furnished based on the comprehensive assessment, and expected outcomes; - The agency failed to provide written notice of patient rights to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to include the rights of the patient and representative (if any) regarding contact information for the home health agency administrator to receive complaints. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all agency patients/representatives. Findings included: The administrator provided an admission packet for review on 08/30/2021. The agency notice of patient rights and other information given to a patient during the initial visit contained no current administrator name for which to receive patient complaints. The word administrator was listed. During an interview on 09/012021, at 4:00 PM, the administrator stated that CHAPs (Community Health Accreditation Partners, a private company to assist agencies to meet government regulations) said the name of the administrator was not necessary to be listed in the admission booklet. The word administrator was all that needed to be listed.

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: Based on policy review and review of the agency's current patient rights information, the agency failed to provide written notice of patient rights regarding their right to have a copy of the patient's rights and responsibilities provided to a patient-selected representative within four business days of the initial evaluation visit. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 showed, in part: - Each patient is an active, informed participant in his/her plan of care; - Every patient receiving service from the agency shall, upon admission, be provided with and have explained, the patient bill of rights and responsibilities including HIPAA and Oasis privacy acts; - A patient may designate someone to act as his/her patient representative; - The Bill of Rights and Responsibilities and the Privacy acts will be explained and distributed to the patient prior to admission to services. This explanation will be in a language he/she can reasonably be expected to understand; and - The cost of services that will be billed to his/her insurance(s) and/or self (verbally and in writing). Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," failed to show patient rights information regarding their right to have a copy of the patient's rights and responsibilities provided to a patient-selected representative within four business days of the initial evaluation visit. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to include the patient has the right to be free from verbal, mental, sexual and physical abuse, including injuries of unknown source, neglect and misappropriation of property. The deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," showed, in part: - The patient has the right to be free from mental, physical, sexual, and verbal abuse, neglect and exploitation; and - The agency failed to include the right to be free from injuries of unknown source, neglect and misappropriation of property. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, and interview, the agency failed to include the patient has the right to make complaints to the home health agency regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the home health agency. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 showed, in part: - Each patient is an active, informed participant in his/her plan of care; - Every patient receiving service from the agency shall, upon admission, be provided with and have explained, the patient bill of rights and responsibilities including HIPAA and Oasis privacy acts; and - The right to voice a complaint/concern regarding care or service. Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," showed, in part: - The right to have your or your family's complaints heard, reviewed and if possible resolved concerning care that is or should have been furnished; - Have the right to know about the results of such complaints; and - The agency's complaint resolution process regarding care, services or a lack of respect for property is explained. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

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: Based on policy review, review of the agency current patient rights information and interview, the agency failed to update the written notice of patient rights to include the patient has the right to participate in, be informed about, and consent or refuse care, with respect to completion of all assessments, care to be furnished based on the comprehensive assessment, and expected outcomes. The deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 showed, in part: - Each patient is an active, informed participant in his/her plan of care; - The right to refuse all or parts of his/her care to the extent permitted by law; - The right to participate in all aspects of care/services; and - The agency failed to include notice with respect to completion of all assessments, care to be furnished based on the comprehensive assessment, and expected outcomes. Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," failed to include: - Completion of all assessments; and - The care to be furnished, based on the comprehensive assessment. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to include the patient has the right to receive all services outlined in the plan of care. The deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 showed, in part: - Each patient is an active, informed participant in his/her plan of care; - Every patient receiving service from the agency shall, upon admission, be provided with and have explained, the patient bill of rights and responsibilities including HIPAA and Oasis privacy acts; and - The policy failed to show the patient had the right to receive all services outlined in the plan of care. Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," failed to show the right to receive all services outlined in the plan of care. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on record review, current patient rights, home visit observation, and interview, the agency failed to ensure the patient was advised orally and in writing of the extent to which payment for services may be expected from Medicare, Medicaid, or any other federally-funded aid program, the charges of services that may not be covered in one (Record/Patient #2) of three home visit observations and one (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to adversely affect the patient's ability to pay for services for all agency's patients. Findings included: Review of the agency's policy titled "Patient Bill of Rights and Responsibilities" dated June, 2010 showed: - Every patient receiving service from the agency shall, upon admission, be provided with and have explained the Patient Bill of Rights and Responsibilities and must receive a copy of the Patient Bill of Rights and Responsibilities on or before admission to service; - The patient is informed at admission of the cost of services that will be billed to his/her insurance(s) and/or self, verbally and in writing; and - The patient will be informed of their responsibilities during care to include providing the agency with timely information with regard to meeting financial obligations for care. RECORD/PATIENT#2: Review of a physician's office information sheet 08/12/2021 showed: - Primary insurance: Medicare Part A and B; and - Secondary insurance: AARP Medicare Supplement. Review of the plan of care (POC) dated 08/13/2021 through 10/11/2021 showed: - Start of care date: 08/13/2021. Review of the Patient Responsibilities, Rights, and Conduct form showed: - Patient responsible for notifying the home care staff if insurance changes and promptly meet financial obligations; - Signed by the patient and registered nurse on 08/13/2021. During a home visit observation on 09/01/2021 at 10:45 AM, the patient's home admission folder showed: - Staff did not complete the financial liability/authorization form for the patient; and - Staff and patient signed the financial liability/authorization form on 08/13/2021. RECORD/PATIENT #5: Review of a referral demographic sheet from the hospital printed 05/25/2021 showed: - Primary insurance: Medicare HMO. Review of the clinical record showed no POC completed upon admission. Review of a skilled nurse (SN) evaluation form dated 06/01/2021 showed: - The evaluation was completed seven days after the referral date; and - Did not address the financial liability/authorization form. Review of the Patient Responsibilities, Rights, and Conduct form showed: - Patient responsible for notifying the home care staff if insurance changes and promptly meet financial obligations; - Signed by the patient and registered nurse on 06/01/2021. Review of the Financial Authorization form dated 06/01/2021 showed: - Staff did not complete the financial liability/authorization form for the patient. The record review findings were presented to the clinical manager on 09/02/2021 and no further information was provided.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, and interview, the agency failed to include the patient has the right to receive proper written notice, in advance of a specific service being furnished, if the agency believes that the service may be non-covered care; or in advance of the agency reducing or terminating on-going care. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 showed, in part: - Each patient is an active, informed participant in his/her plan of care; - Every patient receiving service from the agency shall, upon admission, be provided with and have explained, the patient bill of rights and responsibilities including HIPAA and Oasis privacy acts; - A patient may designate someone to act as his/her patient representative; - The Bill of Rights and Responsibilities and the Privacy acts will be explained and distributed to the patient prior to admission to services. This explanation will be in a language he/she can reasonably be expected to understand; and - The cost of services that will be billed to his/her insurance(s) and/or self (verbally and in writing). Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," showed, in part: - Be informed of the extent to which payment may be expected from Medicare, Medicaid or any other payer known to us before any care is delivered; - Be informed verbally and in writing at the time of admission, the approximate maximum dollar amount, if any, of care or services to be borne by the patient; - Have access to all bills, upon request, for services received regardless of whether the bills are paid out-of-pocket or by another party; - The patient has the responsibility to notify the agency of insurance changes; - Follow the plan of care and instructions and accept responsibility for the outcomes if the patient chooses to not follow the care, treatment or service plan; - Promptly meet financial obligations and responsibilities agreed upon with the agency; - Show respect and consideration for agency staff and equipment; - Carry out mutually agreed responsibilities; and - The agency failed to comply with the requirements of 42 CFR 405.1200 through 405.1204 for Notice of Medicare Non-coverage notification. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

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 review of the agency's current patient rights information, observation, home folder review, and interview, the agency failed to ensure staff provided the written notice of the updated state toll free home health telephone hotline hours of operation in the admission folder of three (Record/Patient #1, #2, and #3) of three home visit observations. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities for all patients/representatives served by the agency. Findings included: Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," showed, in part: - The patient has the right to be advised of the telephone number and hours of the state's home care hotline which receives complaints or questions about local home care agencies; - The hotline also receives complaints concerning the implementation of advance directive requirements; and - The hotline will be answered 24 hours per day. RECORD/PATIENT #1: A home visit observation on 08/31/2021 at 1:15 PM showed: - The patient folder contained information that the hotline will be answered 24 hours a day; and - The agency failed to update the patient folder to include the correct hours the hotline will be answered. RECORD/PATIENT #2: A home visit observation on 09/01/2021 at 10:45 AM showed: - The patient folder contained information that the hotline will be answered 24 hours a day; and - The agency failed to update the patient folder to include the correct hours the hotline will be answered. RECORD/PATIENT #3: A home visit observation on 08/031/2021 at 10:00 AM showed: - The patient folder contained information that the hotline will be answered 24 hours a day; and - The agency failed to update the patient folder to include the correct hours the hotline will be answered The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to include the name, address and phone number of the current Quality Improvement Organization (QIO) that serves the area where the patient resides. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the current patient rights information failed to include: - The current QIO organization; and - The agency failed to list the current complete QIO information for: * Livanta LLC BFCC-QIO Program 10820 Guilford Road, Suite 202 Annapolis Junction, MD 20701-1105 Phone No 1-888-755-5580 TTY: 1-888-985-9295 The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

Access to auxiliary aids and language service CFR(s): 484.50(c)(12) Be informed of the right to access auxiliary aids and language services as described in paragraph (f) of this section, and how to access these services. This ELEMENT is not met as evidenced by: Based on review of the agency current patient rights information and interview, the agency failed to provide the written notice of patient rights to include the patient has the right to be informed of the right to access auxiliary aids and language services and how to access these services. The deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 showed, in part: - Each patient is an active, informed participant in his/her plan of care; and - In the event a communication barrier exists, if possible, special devices or interpreters shall be made available. Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," showed, in part: - As a Home Care provider, we have an obligation to protect your rights and explain these rights to you in a way you can understand before treatment begins and on an ongoing basis, as needed; - The patient has the right to receive information in a manner that they can understand; and - The agency failed to include the patient has the right to be informed of the right to access auxiliary aids and language services and how to access these services. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the agency can no longer meet the patient's needs. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 failed to show that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the agency can no longer meet the patient's needs. Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," showed, in part: - The agency failed to update the written notice of patient rights to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the agency can no longer meet the patient's needs. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

Patient/payer will no longer pay for services CFR(s): 484.50(d)(2) The patient or payer will no longer pay for the services provided by the HHA; This ELEMENT is not met as evidenced by: Based on agency policy review, review of the agency current patient rights information and interview, the agency failed to update the written notice of patient rights to include the agency may discharge or transfer from the agency if the patient or payer will no longer pay for services provided by the agency. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 failed to show the patient has the right to be informed that the agency may discharge or transfer the patient from the agency if the patient or payer will no longer pay for services provided by the agency. Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," showed, in part: - Be informed of the extent to which payment may be expected from Medicare, Medicaid or any other payer known to us before any care is delivered; - Be informed verbally and in writing at the time of admission, the approximate maximum dollar amount, if any, of care or services to be borne by the patient; - Have access to all bills, upon request, for services received regardless of whether the bills are paid out-of-pocket or by another party; - The patient has the responsibility to notify the agency of insurance changes; - Promptly meet financial obligations and responsibilities agreed upon with the agency; and - The agency notice of patient rights contained no written information regarding that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the patient or payer can no longer pay for the services. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

Outcomes/goals have been achieved CFR(s): 484.50(d)(3) The transfer or discharge is appropriate because the physician or allowed practitioner, who is responsible for the home health plan of care and the HHA agree that the measurable outcomes and goals set forth in the plan of care in accordance with §484.60(a)(2)(xiv) have been achieved, and the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the patient no longer needs the HHA's services; This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to include the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the physician and agency agree that the outcomes and goals have been achieved and the patient no longer needs the agency services. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 failed to show information regarding the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the physician and agency agree that the outcomes and goals have been achieved and the patient no longer needs the agency services. Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," showed, in part: - The agency notice of patient rights contained no written information regarding the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the physician and agency agree that the outcomes and goals have been achieved and the patient no longer needs the agency services. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information and interview, the agency failed to update the written notice of patient rights to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the patient refuses services or elects to be transferred or discharged. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 failed to show that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the patient refuses services or elects to be transferred or discharged. Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," showed, in part: - The agency notice of patient rights contained no written information regarding that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge when the patient refuses services or elects to be transferred or discharged. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to include that the agency policy for discharge for cause: - Determines that the patient's or other persons in the home, behavior is disruptive, abusive or uncooperative to extent that the delivery of care to the patient or the ability of the agency to operate effectively is impaired; and - Then the agency must follow the requirements of paragraphs (d) (5) (i) through (d) (5) (iii) of this section. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 failed to show the agency policy for discharge for cause. Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," showed, in part: - The agency notice of patient rights contained no written information regarding the patient rights when the agency determines that the patient's or other persons in the home, behavior is disruptive, abusive or uncooperative to extent that the delivery of care to the patient or the ability of the agency to operate effectively is impaired and the patient is being considered for discharge for cause. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's 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) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to include that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, that a discharge for cause is being considered. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 failed to show that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, that a discharge for cause is being considered. Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," showed, in part. the agency notice of patient rights contained no written information regarding that the agency must advise the patient or representative, physicians, and healthcare professionals who will be responsible for providing care after discharge, that a discharge for cause is being considered. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to include that the agency must document the problem and efforts made to resolve the problem, if the patient is considered for discharge for cause. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 failed to show that the agency must document the problem and efforts made to resolve the problem, if the patient is considered for discharge for cause. Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," showed, in part, the agency notice of patient rights contained no written information regarding the patient's right to be informed that if the patient is considered for discharge for cause, the agency must document the problem and efforts made to resolve the problem. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

Death of patient CFR(s): 484.50(d)(6) The patient dies; or This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to include that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the patient dies. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 failed to show that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the patient dies. Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," showed, in part, the agency notice of patient rights contained no written information regarding that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the patient dies. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

HHA ceases to operate CFR(s): 484.50(d)(7) The HHA ceases to operate. This ELEMENT is not met as evidenced by: Based on policy review, review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to include the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the agency ceases to operate. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 failed to show the patient has the right to be informed of the agency's policies for transfer and discharge if the agency ceases to operate. Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," showed, in part. the agency notice of patient rights contained no written information regarding that the patient and representative (if any) have a right to be informed of the agency's policies for transfer and discharge if the agency ceases to operate. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

Accessibility CFR(s): 484.50(f)(1,2) Standard: Accessibility. Information must be provided to patients in plain language and in a manner that is accessible and timely to- (1) Persons with disabilities, including accessible web sites and the provision of auxiliary aids and services at no cost to the individual in accordance with the Americans with Disabilities Act and Section 504 of the Rehabilitation Act. (2) Persons with limited English proficiency through the provision of language services at no cost to the individual, including oral interpretation and written translations.Standard: Accessibility Information must be provided to patients in plain language and in a manner that is accessible and timely to- This STANDARD is not met as evidenced by: Based on policy review review of the agency's current patient rights information, and interview, the agency failed to update the written notice of patient rights to include that information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services are at no cost to the individual and must be provided to persons with limited English proficiency, at no cost to the individual including oral interpretation and written translations. This deficient practice has the potential to affect the knowledge and comprehension of the rights and responsibilities of all agency patients. Findings included: Review of the agency's policy titled, "Patient Bill of Rights and Responsibilities," dated June, 2010 failed to show that information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services are at no cost to the individual and must be provided to persons with limited English proficiency, at no cost to the individual including oral interpretation and written translations. Review of the agency's undated current patient rights information sheet titled, "Your Rights & Responsibilities," showed, in part: - As a Home Care provider, we have an obligation to protect your rights and explain these rights to you in a way you can understand before treatment begins and on an ongoing basis, as needed; - The patient has the right to receive information in a manner that they can understand; and - The agency notice of patient rights contained no written information regarding the patient's right to be informed about how information must be provided to patients in a language and in a manner that is accessible and timely to persons with disabilities, including accessible web sites and the provision of auxiliary aids services are at no cost to the individual and must be provided to persons with limited English proficiency, at no cost to the individual including oral interpretation and written translations. The findings were reviewed with the administrator on 09/01/2021 at 4:00 PM. No additional information was provided.

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 policy review, clinical record review, and interview, the agency failed to conduct the initial assessment of the patient within 48 hours of the referral to home care, or 48 hours after the patient's return home, or on the physician ordered start of care date in two (Record/Patient #3 and #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled "Initial Assessment" dated June, 2013 showed: - All patients discharging from a facility must have initial assessment within 24 hours of discharge; - Referrals from a physician's office must have the initial assessment within 48 hours; and - If a patient does not allow initial assessment within these time frames, a physician order must be obtained to reflect later assessment. RECORD/PATIENT #3: Review of the referral information showed a physician signed the home health order dated 08/23/2021 and showed: - Requested medical service: Home health (new episode) - Opening discipline: Physical therapy; and - Additional discipline: Occupational therapy (OT). Review of the clinical record showed physical therapy evaluation dated 08/27/2021 (four days after the referral for home health). During an interview on 09/01/2021 at 12:14 PM, the PT stated the following: - The therapy agency received the referral from the home health agency on 08/25/2021 (two days after the home health agency received the referral); - He/she admitted the patient on 08/27/2021; and - PT does the start of care within 48 hours of receiving the referral. During an interview on 09/01/2021 at 4:41 PM, the clinical manager stated an assessment does not have to be within 48 hours of the referral if the patient is not a Medicare patient. Physical therapy has five days to do an assessment unless the patient refuses. RECORD/PATIENT #4: Review of the Physician Home Health Order dated 02/08/2021 from the physician's office showed: - Evaluate and treat; - Nursing, physical therapy, and occupational therapy; - Signed by the physician on 02/08/2021. Review of the start of care (SOC) assessment dated 02/13/2021 showed: - No specific SOC date ordered by the physician; - Date of referral documented as 02/12/2021; and - Assessment date of 02/13/2021 was conducted five days after the referral by the physician's office. - No other order found for referral date of 02/12/2021. Review of the clinical record showed no order from the physician for a specific date of admission/assessment to home health or a referral date of 02/12/2021. During an interview on 08/31/2021 at 12:30 PM, the administrator stated the following: - When a patient is referred to the agency the clinical manager was responsible to get orders and communicate with the physician; - He/she would expect a visit within 48 hours to 72 hours; - If the insurance requires pre-authorization he/she would expect the office to get authorization first; - Some orders they receive require the insurance company pre-authorization before they see the patient; - This can take weeks and weeks to get authorization; and - If this happens they will contact the patient and tell them this is the order and whenever they get authorization the agency will see 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: Based on policy review, record review, home visit observation, and interviews, the agency failed to ensure the patient's medications were reconciled during the start of care comprehensive assessment in, one (Records/Patients # 3) of five full records reviewed. This deficient practice has the potential to adversely affect the accuracy and safety of medication administration for all the agency's patients. Findings included: Review of the agency's policy titled, "Medication Profile" dated 01/31/2014, showed, in part, the following: - Upon admission, the admitting clinician will initiate a medication sheet documenting all current medications being taken by the patient including dosage, route and frequency; - Reconcile all medication lists that may be present at the time of admission and all medications that are found in the home; - Any discrepancies (omissions, duplications, potential interactions) must be resolved; and - A copy of the correct medication sheet will be left in the patient's home folder Review of a physician face to face encounter, dated 08/12/2021 showed the following medications: - Metformin (anti-diabetic medication) 500 mg (milligrams), two tablets twice a day; - Acetaminophen 500 mg one tablet three times a day; - Gabapentin (anticonvulsant) 100 mg, one capsule three times a day; - Ducosate Sodium (stool softener) 100 mg, one capsule every night at bedtime; and - Levetiracetam (anti-convulsant) 500 mg, one tablet two times a day. Review of the physical therapy (PT) evaluation dated 08/27/2021, showed the following: - Medical diagnosis sequelae of cerebral vascular accident (stroke) and right hemiparesis (weakness); and - Right hip pain relieved by Tylenol, Gabapentin (anticonvulsant) and rest; Review of the physical therapy treatment plan dated 08/27/2021 showed no medications listed or reconciled. During the home visit observation on 08/31/2021 at 10:00 AM, showed the following medications: - Metformin (anti-diabetic medication) 500 mg (milligrams), two tablets twice a day; - Acetaminophen 500 mg one tablet three times a day; - Gabapentin 300 mg, three times a day; - Lisinopril (treats high blood pressure and heart failure) 2.5 mg every day; - Metoprolol (treats high blood pressure) 125 mg every day; and - Lantus (treats diabetes) 10 units every day. The agency failed to reconcile the patient's medications. The information was reviewed with the clinical manager on 08/31/2021 at 11:00 AM and 3:45 PM and he/she stated the physical therapy evaluation and treatment plan was sent to the physician for signature. PT does their own medication reconciliation and if there is a delay in getting physician orders he/she will "step in". No further information was provided.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on policy review, clinical record review, observation, and interview, the agency failed to: - Provide an individualized plan of care that included, but not limited to, all pertinent diagnoses, the types of services, supplies, and equipment required, the frequency and duration of visits to be made, all medications and treatments (G574); - Provide drugs, services, and treatments that were administered only as ordered by a physician or allowed practitioner (G580); - Coordinate care delivery to meet the patient's needs, and involve the patient/representative (if any), and caregiver(s), as appropriate in the coordination of care activities (G608); - Ensure each patient/caregiver receivee ongong education and training provided as appropriate, regarding the care and services identified on the plan of care, in ensure a timely discharge (G610); - Provide a written visist schedule including frequency of discipline visits (G614); - Provide a written medication schedule and instructions to include medication name, dosage, and which medications will be administered by the home health agency (G616); - Provide any treatments to be adminstered by the home health agency staff, including therapy services (G618); and - Provide the name and contact information of the agency clinical manager (G622). The cumulative effect of these deficient practices has the potential to affect the provision of safe care for all patients served by the agency.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, observation, and interview, the agency failed to ensure that each patient's written individualized plan of care (POC) included all required elements in three (Record/Patient #1, #2 and #3) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy dated 06/2010 titled "Care Planning" showed: - Plan of Care definition: The clinical plan of treatment, including a comprehensive assessment which includes the current version of OASIS (Outcome and Assessment Information Set) dataset elements, pertinent diagnoses, types of services/equipment/medical supplies needed, frequency of visits, goals and interventions appropriate to each discipline, prognosis, rehabilitation potential, functional limitations, precautions, activities, mental status, nutrition requirements, medications, treatments, safety measures and discharge plans; - The plan of care is based upon the physician's orders and encompasses the equipment, supplies and services required to meet the patient's needs; - At the time of the admission visit, the primary clinician develops the patient plan of treatment based upon the patient's identified needs and reviews it with the patient and family or caregiver(s); - Services to be provided will be based on the prioritized needs of the patient; - Care decisions and outcome development will be made as a result of the care planning process and analysis of assessment visit including but not limited to: * Identified patient problems and needs identified by the comprehensive assessment; * Interventions to be utilized to meet the patient goals and/or outcomes; and * Clinicians will inform the patient's physician of any changes which may indicate a need for change in the plan of treatment. . RECORD/PATIENT #1: Review of the plan of care (POC) dated 08/17/2021 through 10/15/2021 showed, in part, the following: - Diagnosis included unspecified diastolic (congestive) heart failure, hypertrophic osteoarthropathy (hypertrophic condition that is marked by clubbing of the fingers and toes, painful swollen joints, and periostitis and subperiosteal bone formation chiefly affecting the long bones), burn of unspecified degree of right lower leg, pressure-induced deep tissue damage of unspecified heel, unspecified wound of left great toe with damage to nail, laceration (cut) to left foot; - The POC did not include diabetes mellitus (abnormally high blood glucose/sugar levels); - The POC showed Metformin HCL (anti-diabetic medication) 850 mg (milligrams), one tablet twice daily; - The POC showed Levemir (long acting insulin to treat/control high blood sugar in adults with diabetes) subcutaneous 100 units/ml (milliliter) taking 10 units at bedtime daily; - The POC showed to instruct on signs and symptoms of hyperglycemia (high blood glucose levels), glucometer (measures how much glucose is in the blood) use and preparation and administration of diabetic medications ordered by the physician; - The POC did not include parameters for high blood glucose levels, or how often the patient was to check his/her blood sugars; - Durable medical equipment (DME) and supplies: cane, probe covers, exam gloves and walker; - The agency failed to list the glucometer under the DME and supplies; - Silver sulfadiazine (stops the growth of bacteria that may infect an open wound) external 1% 400 grams apply twice daily to effected area; - Menthol-zinc oxide (used to treat and prevent minor skin irritations) external apply to affected area twice daily; - Both Silver sulfadiazine and Menthol-zinc oxide, (topical medications applied to skin) failed to show on the plan of care the specific area of the body to be applied; - The POC showed the patient's left toe was swollen and inflamed, he/she had a cut on his/her heel and stubbed his/her left toe, the patient had been applying triple antibiotic on it and had it covered with a soiled bandage, the area was assessed, cleaned and new bandage was applied and new wound care supplies have been ordered for the patient; - The plan of care failed to show physician orders for treatment to the left toe and the left heel; - The POC showed skilled nurse to assess pain level; and - The POC failed to show pain parameters and when to report to the physician. ` ` During an interview on 08/30/2021 at 3:25 PM the clinical manager stated: - There was no diabetes listed on the first referral so he/she had to get a second referral; - He/she didn't think the patient was using the menthol-zinc oxide and silver sulfadiazine but during today's visit the patient said he/she was; - The clinical manager was confused to the type of treatment to the left toe and heel, the treatment frequency, and what the order was; - The patient can do his/her own blood sugar checks but he/she needs more care than he/she was getting right now; and - No further information was provided. RECORD/PATIENT #2: Review of the start of care OASIS (Outcome and Assessment Information Set, is a comprehensive assessment designed to collect information related a patient's plan of care in the home) dated 08/13/2021 showed: - Start of care (SOC) date: 08/13/2021; - Diagnoses included but not limited to: Unspecified heart failure, Type 2 diabetes mellitus (abnormally high blood glucose/sugar levels treat with medications), did not include stasis ulcers to bottom of right toe, wound to right small toe, and three wounds to the left lateral foot; - Did not include parameters for hyperglycemia (high blood glucose levels) or hypoglycemia (low blood glucose levels), monitoring of blood glucose levels, or when to notify the physician of abnormal levels; and - Did not include wound care interventions. Review of the POC dated 08/13/2021 through 10/11/2021 showed: - Diagnoses included but not limited to: Non-pressure chronic ulcer to foot, polyneuropathy (damage to multiple nerves outside of the brain and central nervous system that can cause pain, discomfort, and mobility difficulties), and Type 2 diabetes mellitus; - Skilled nurse (SN) to instruct patient/caregiver on wound care: - Wound care not documented; - SN to instruct on all aspects of diabetic management to include disease process, foot assessments, signs and symptoms of hypoglycemia and hyperglycemia, glucometer (machine to check blood glucose levels) use and preparation and administration of diabetic medications ordered by the physician; - Did not include parameters to contact physician of abnormally high or low blood glucose levels; and - Did not list wound care supplies in DME and supplies section of the POC. During an interview on 09/01/2021 at 4:00 PM, the director of nursing/clinical manager stated that: - Parameters for blood glucose levels for hypoglycemia and hyperglycemia should be listed on the POC; and - No other information provided. RECORD/PATIENT #3: Review of the physical therapy (PT) evaluation dated 08/27/2021, showed the following: - Medical diagnosis sequelae of cerebral vascular accident (stroke) and right hemiparesis (weakness); - PT diagnosis non ambulatory, impaired bed mobility and transfers, and weakness; - Patient has complained of pain at rest, reports pain in right hip and reports white skin spot on buttock; - Right hip pain relieved by Tylenol, gabapentin (anticonvulsant) and rest; - The patient and caregiver state the patient has a white skin spot on buttock and that they have received medication from the physician; and - Skin wound appearing on buttock, physician contacted regarding skin issue and physical therapy awaiting physician office to authorize a skilled nursing evaluation. Review of the physical therapy (PT) treatment plan (plan of care) dated 08/27/2021 failed to show the following: - Diagnosis; - Medications; - Oxygen saturation parameters and when to notify the physician; - Buttock wound treatment; - Instruction for positioning; - List of home exercises; and - The patient's right hip pain and interventions. The information was reviewed with the clinical manager on 08/31/2021 at 11:00 AM and 3:45 PM, he/she stated the PT evaluation is the plan of care. Staff read the PT evaluation note section for the plan of care. The physical therapy evaluation and treatment plan were sent to the physician for signature. No further information was provided. During an interview on 09/01/2021 at 12:14 PM, the PT stated the following: - He/she admitted the patient on 08/27/2021; - He/she called the physician to get a nurse out there; - The patient had pain everywhere, in his/her lower back, right hip and mostly joints; - He/she doesn't remember the patient rating his/her pain but it would be in his/her notes and it was part of the assessment; - The patient had a white spot on his/her upper buttocks, it was not open or broken down; - The patient hasn't been out of bed or turned and he/she provided education; and - The plan of care is created from the oasis assessment.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and interview, the agency failed to ensure staff obtained physician signed plans of care for orders and treatments and verbal or telephone orders in a timely manner which affected two (Record/Patient #4 and #6) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled "Care Planning" dated June, 2010 showed: - Signed physician's orders will be in the patient's clinical record prior to final billing of services for each individual patient; and - The plan of care (POC) is based upon the physician's orders and encompasses the equipment, supplies, and services required to meet the patient's needs. RECORD/PATIENT #4: Review of the POC dated 02/12/2021 through 04/13/2021 showed: - Diagnoses included but not limited to: UTI (urinary tract infection), diabetes mellitus (uncontrolled blood glucose levels), congestive heart failure (excessive fluid around the heart), atrial fibrillation (rapid hear beat that can cause death), and repeated falls; - Skilled nurse (SN) 2w9 (visit two times per week for nine weeks); - Physical therapy (PT) 1w1, 2w3, and 1w3; - Occupational therapy (OT) 1w1, and 2w2; - 11 medications for reconciliation, teaching to the patient/caregiver as needed and monitoring as needed for correct administration; - Orders and treatments for the SN to perform; - Signed by the physician on 06/10/2021, six months after the initial start of care (SOC). Review of a faxed order for social worker evaluation dated 03/04/2021 not signed by the physician as of the survey exit date 09/02/2021. Review of a verbal order dated 03/17/2021 showed a medication change effective 03/17/2021 not signed by the physician as of the survey exit date of 09/02/2021. Review of a recertification POC dated 06/02/2021 through 07/31/2021 showed no physician signature as of the survey exit date of 09/02/2021. Review of a physician's order for the social worker to evaluate the patient for meals on wheels dated 06/10/2021 not signed by the physician as of the survey exit date of 09/02/2021 Review of the recertification POC dated 08/01/2021 through 09/29/2021 showed no physician signature as of the survey exit date of 09/02/2021. RECORD/PATIENT #6: Review of the POC dated 06/29/2021 through 08/27/2021 showed: - Diagnoses included but not limited to: Hemiplegia (paralysis of one side), cerebral infarct (stroke), aphasia (inability to speak), diabetes mellitus, chronic congestive heart failure, artificial right knee joint, fall, and hypertension (high blood pressure); - 18 medications for reconciliation, teaching to the patient/caregiver as needed, and monitoring for correct administration as needed; - Orders and treatments for the PT and OT to perform; - PT 2w1, 3w2, and 2w3; - OT 1w1, and 2w3; and - Signed by the physician on 07/26/2021, 27 days after the initial SOC. Review of the OT evaluation with orders for treatment dated 07/01/2021 showed the physician signed the evaluation 11 days after the OT evaluation completed. During an interview on 09/01/2021, the clinical manager/director of nursing stated that: - Staff faxed orders weekly or twice monthly; - Some physicians got upset because the agency faxes too many orders; and - Doctors have stopped referring patients because of so many orders faxed to them.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on review of policy, clinical record review and interview the agency failed to ensure coordination of care delivery to meet the patient's needs in one (Record/Patient #3) of five records reviewed. This deficient practice has the potential to affect the coordination of care and services for all patients on service with the agency. Findings included: Review of the agency's policy dated 06/2010 titled "Communications in Care" showed: - Timely and on-going communication is the responsibility of each discipline member assigned to a case, and will be appropriate to the needs and abilities of the patient and relevant to the care or service provided; - The patient's primary clinician will be responsible for facilitating communications about changes in the patient status between assigned personnel' - Procedure: * Agency personnel will communicate changes in a timely manner via telephone, one-to-one meetings, case conferences and home visits; * Communicate with other disciplines involved in care will be done no less than once for every 30 days of care; * Documentation of all communications will be included in the clinical record on a communication note, case conference summary, and/or visit note; and * Documentation will include: the date and time of the communication, individuals involved with the communication, including professional title, information discussed, and the outcome of the communication. Review of the agency's policy dated 06/2010 titled "Care Planning" showed: - The plan of care is based upon the physician' orders and encompasses the services required to meet the patient's needs; - At the time of the admission visit, the primary clinician develops the patient plan of treatment based upon the patient's identified needs and reviews it with the patient and family or caregiver(s); - Services to be provided will be based on the prioritized needs of the patient; - Care decisions and outcome development will be made as a result of the care planning process and analysis of assessment visit including but not limited to: * Identified patient problems and needs identified by the comprehensive assessment; * Interventions to be utilized to meet the patient goals and/or outcomes; and * Clinicians will inform the patient's physician of any changes which may indicate a need for change in the plan of treatment. RECORD/PATIENT #3: Review of the physical therapy (PT) evaluation dated 08/27/2021, showed the following: - The patient was admitted for services on 08/27/2021; - Medical diagnosis sequelae of cerebral vascular accident (stroke) and right hemiparesis (weakness); - PT diagnosis non ambulatory, impaired bed mobility and transfers, and weakness; - Patient has complained of pain at rest, reports pain in right hip and reports white skin spot on buttock; - Right hip pain relieved by Tylenol, gabapentin (anticonvulsant) and rest; - The patient and patient's spouse stated there is a white skin spot on buttock and that they have received medication from the physician; - Skin: Wound appearing on buttock, physician contacted regarding skin issue and physical therapy awaiting physician office to authorize a skilled nursing evaluation; - There was care coordination with the physical therapy assistant and the occupational therapist and no care coordination with skilled nursing; and - The agency was called at 1:15 PM (there was no documentation to show why they were called). During the home visit, with the clinical manager and occupational therapist, observation and interview on 08/31/2021 at 10:00 AM, showed the following: - Occupational therapy (OT) turned the patient onto his/her side so the surveyors could observe the patient's buttocks. The patient had a stage II pressure ulcer (partial thickness tissue loss) on his/her upper right buttock/coccyx area measuring approximately 6 centimeters (cm) by 4 cm; - The clinical manager stated he/she did not know about the wound on the patient's buttocks and did not look at the wound when OT turned the patient on his/her side; - The patient's family member stated the patient had some skin breakdown about a week ago and when he/she saw the wound on this date, he/she said "oh, that's worse than last week, the wound is bigger today"; - The clinical manager told the patient's spouse and family member that wedges were needed to prop the patient up and the patient's spouse said the patient won't stay on his/her side; - The clinical manager instructed the patient's spouse to turn the patient every two hours; and - The patient's spouse stated he/she had been putting Cerave moisturizing cream on the pressure areas, the doctor was supposed to call in an order for it (the wound) but never did. During interview on 08/31/2021 at 3:43 PM, the clinical manager stated the following: - The physician did not get back with them regarding the patient's buttocks; - PT does not usually assess the patient, nursing does; - If PT cannot get a hold of the clinical manager they call the office to send for orders; - The physician was not notified of the skin break down; - He/she would have expected the office to be notified of the problem when PT got the order; and - The agency calls when the physician calls to take the order. During an interview on 09/01/2021 at 10:47 AM, the clinical manager stated the following: - He/she contacted the physician's office yesterday (08/31/2021) to see if they would send an order for a skilled nursing evaluation. There was nothing in the portal to show that physical therapy sent orders or called the physician regarding the pressure ulcer so she contacted the physician on 09/01/2021 (five days after skilled nurse visit requested) at 8:30 AM to let them know how serious the pressure ulcer got and he/she received orders for skilled nursing to evaluate; - He/she would have known about the pressure ulcer if the physical therapist (PT) would have notified him/her directly; - The protocol is: * Therapy is to call the office if there is an issue; * The intake coordinator or receptionist is to call the physician and report the issue and ask for an evaluation; * The intake coordinator or receptionist get insurance authorization; * Then notify the clinical manager; - He/she did not look at the patient's pressure ulcer yesterday (08/31/2021) because they didn't have insurance authorization or physician order and he/she has to have a physician order in hand and financial consent before he/she can do a visit; and - Physical therapy does not do a detailed assessment when they admit a patient, they contact nursing or the office if there are any issues. During an interview on 09/07/2021 at 11:00 AM, the receptionist stated PT notified him/her last Friday 08/27/2021 the patient had a wound and they (PT) notified the physician's office so they could put a work order in for nursing. He/she failed to notify the intake coordinator and clinical manager. During an interview on 09/01/2021 at 12:14 PM, PT stated the following: - He/she admitted the patient on 08/27/2021; - He/she tried to roll the patient over but had no one to help him/her but the patient was in a lot of pain; - He/she called the physician to get a nurse out there; - The patient had pain everywhere, in his/her lower back, right hip and mostly joints; - He/she doesn't remember the patient rating his/her pain but it would be in his/her notes and it was part of the assessment; - The patient had a white spot on his/her upper buttocks, it was not open or broken down (PT said he/she was unable to assess the wound because he/she couldn't roll the patient over); - The patient hasn't been out of bed or turned and he/she provided education; - He/she called the agency with orders and whoever he/she talked to added it in the computer by going to the hot box (a part of the computer program) and adding a sticky note about the wound; - He/she talked to a nurse at the physician's office and got verbal orders for skilled nursing to evaluate the patient and put it in the electronic medical records so the clinical manager would see it (there were no physician orders for skilled nursing in the patient's medical record); and - He/she followed up with the physician (regarding the order for skilled nursing) on 08/31/2021 (four days after the family and patient reported the white spot on the patient's buttock) through k-mail (internal agency email system) which is now gone.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on policy review, home visit observation, record review, and interview, the agency failed to ensure staff provided patient's ongoing education and training in, but not limited to, one (Records/Patients #1) of five records reviewed. This deficient practice has the potential to affect all patients served by the home health agency. Findings included: Review of the agency policy titled, "Monitoring Response to Care," dated 06/2010, showed, in part, that each patient will be monitored on an on-going bases for response to care, evaluation of goals and interventions being provided, outcomes of care and services being provided and changes in patient status. During each home visit, the clinician will monitor the patient's response to care, including teaching. RECORD/PATIENT #1: Review of the plan of care (POC) dated 08/17/2021 through 10/15/2021 showed, in part, the following: - Tramadol Hcl (used to treat moderate to severe pain) 50 mg (milligrams), one tablet every four hours for pain; - Levemir (treats diabetes) subcutaneous injection 10 units at bedtime daily; - Skilled nurse to instruct patient to take medication before pain becomes severe to achieve better pain control; and - Skilled nursing to instruct patient/caregiver on all aspects of diabetic management to include disease process, foot assessments, signs and symptoms of hyperglycemia, glucometer use and preparation and administration of diabetic medications ordered by physician. During the home visit, with the clinical manager, observation and interview on 08/31/2021 at 1:15 PM, showed the following: - The patient said he/she was in a lot of back pain, the pain was constant and rated the pain an 8 on a scale of 0-10 with 10 being the worst pain; he/she said the Tramadol does not last long and he/she took it morning and night (twice a day); - The clinical manager did not educate the patient that Tramadol was scheduled every four hours as needed; - The clinical manager did not instruct the patient to take pain medication before pain becomes severe to achieve better pain control; - The patient said his/her blood sugar was 221 mg/dl which is normal for him/her and has been up to 360 mg/dl and he/she injects more insulin if the blood sugar was over 250 mg/dl; - The patient had syringes filled with 14 units of a milky substance, which he/she said was insulin that his family member prefilled, and he/she just uses one of the syringes when his/her blood sugar is over 250 mg/dl; - He/she took 14 units of insulin at bedtime; and - The clinical manager failed to provide education on any aspect of diabetic management, including disease process, signs and symptoms of hyperglycemia, preparation and administration of diabetic medications ordered by the physician; and - The clinical manager failed to educate the patient on taking extra insulin (which was not on the plan of care). During an interview on 08/31/2021 at 3:00 PM, the clinical manager acknowledged the findings and provided no additional information.

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 review of the patient rights left in the home admission folder, home visit observation, and interview, the agency failed to provide a written visit schedule that included disciplines that would visit and the frequency of visits in two (Record/Patient #1 and #2) of three home visit observations performed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the Center for Medicare and Medicaid Services Conditions of Participation: Patient's Rights 484.50 (c) (4) found in the admission folder left in patient's homes at the time of admission to service showed: - The patient has the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to, (but not limited to) the disciplines that will furnish care and the frequency of visits. RECORD/PATIENT #1: Review of the plan of care (POC) dated 08/17/2021 through 10/15/2021 showed: - Skilled nurse (SN) 1w8 (one visit per week for eight weeks). A home visit observation on 08/31/2021 at 1:15 PM showed: - A blank monthly calendar in the home admission folder and no discipline visits were recorded. RECORD/PATIENT #2: Review of the POC dated 08/13/2021 through 10/11/2021 showed: - Skilled nurse (SN): 2w1 and 1w7. Review of the physical therapy (PT) evaluation dated 08/16/2021 showed: - PT: 2w6. Review of the occupational therapy (OT) evaluation dated 08/26/2021 showed: - OT: 1w1 and 2w3. A home visit observation on 09/01/2021 at 10:45 AM showed: - A visit calendar with only PT visits documented; and - No SN or OT visits documented on the calendar. The record review findings were presented to the clinical manager on 09/01/2021 at 4:00 PM and no further information was provided.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on home visit observation and interview, the agency failed to provide the patient/caregiver with an updated/current copy of written instructions outlining the patient's medication schedule, including medication name, dosage, and frequency in one (Record/Patient #1) of three home visit observations performed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled "Medication Profile" dated 01/31/2014 showed: - All patients will have a current, accurate medication record in the clinical record; - Upon admission, the admitting clinician will initiate a medication sheet documenting all current medications being taken by the patient including dosage, route, and frequency and reconcile all medication lists found in the home. Any discrepancies must be resolved. - A copy of the correct medication sheet will be left in the patient's home folder. RECORD/PATIENT #1: A home visit observation on 08/31/2021 at 1:15 PM showed; - No updated/current medication profile list left in the patient's home admission folder; - The patient provided a copy of a hospital medication list. During an interview on 09/01/2021 at 4:00 PM, the director of nursing/clinical manager stated that updated/current medication profile lists are taken to the patient home with each visit. A current copy should be left in the home.

Treatments and therapy services CFR(s): 484.60(e)(3) Any treatments to be administered by HHA personnel and personnel acting on behalf of the HHA, including therapy services. This ELEMENT is not met as evidenced by: Based on home visit observation and interview, the agency failed to provide the patient/caregiver with a copy of written instructions of any treatments being administered by the agency in two (Record/Patient #1 and #2) of three home visits performed. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1: Review of the plan of care (POC) dated 08/17/2021 through 10/25/2021 showed in part: - Diagnoses included but not limited to: Pressure induced deep tissue damage of unspecified heel, unspecified wound of the left great toe with damage to the nail, laceration without foreign body left foot, and burn of unspecified degree of right lower leg; and - Did not include wound care for the wounds, A home visit observation on 08/31/2021 at 1:15 PM with the director of nursing/clinical manager (DON/CM), the surveyor observed the patient's home admission packet. The agency failed to provide written instructions for care of wounds to the patient. During an interview of 08/31/021 at 1:15 PM during the home visit, the DON/CM stated that staff do not leave education material in the home because staff verbally educate patients. RECORD/PATIENT #2: Review of the POC dated 08/13/2021 through 10/11/2021 showed: - Diagnoses included but not limited to: Non-pressure chronic ulcer to right foot, unspecified severity, and type 2 diabetes mellitus (unstable blood glucose levels treated with medications) with other circulatory complications; - No wound orders specified; and - No blood glucose level parameters to notify the physician documented on the POC. A home visit observation on 09/01/2021 at 10:45 AM with the physical therapy assistant, the surveyor observed the patient's home admission packet. The agency failed to provide written instructions for care of wounds and instructions as to when to notify the physician related to abnormally high or low blood glucose levels to the patient.

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 home visit observation and interview, the agency failed to ensure staff provided in writing the name and contact information of the clinical manager in, three (Record/Patient #1, #2, and #3) of three home visit observations. This deficient practice has the potential to affect all patients served by the agency. Findings included: RECORD/PATIENT #1: During a home visit observation on 08/31/2021 at 1:15 PM with the director of nursing/clinical manager, the surveyor observed the patient's home folder. The folder in the home did not show the name and contact information of the agency's clinical manager. RECORD/PATIENT #2: During a home visit observation on 09/01/2021 at 10:45 AM with the physical therapy assistant (PTA), the surveyor observed the patient's home folder. The folder in the home did not show the name and contact information of the agency's clinical manager. RECORD/PATIENT #3: During a home visit observation on 08/31/2021 at 10:00 AM, with the occupational therapist (OT), the surveyor observed the patient's home folder. The folder in the home did not show the name and contact information of the agency's clinical manager. The findings were reviewed with the director of nursing/clinical manager on 09/01/2021 at 4:00 PM and no other information was provided.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on agency policy, observation, and interview, the agency failed to ensure there was evidence of a Quality Assurance and Performance Improvement (QAPI) program for the agency. The cumulative effect of this deficient practice has the potential to affect the quality of care and safety of all agency patients. Findings included: Review of the agency's undated policy titled "Performance Improvement Program" showed: - Philosophy: Performance improvement calls for a cease in dependence on inspection and a move to process development. A series of well-defined projects should be established with commitment of leaders and staff who are ready to take the responsibility, no matter the outcome of our efforts; - Objectives: Integrate standards of patient care, standards of practice and standards of performance into quality of care and outcome measures; - Institute data collection, monitoring, and feedback report systems to provide aggregated data for quality controls and positive patient outcomes; - Continuously pursue opportunities to improve quality of patient care by implementing agency processes and educational offerings, altering performance methods, making policy revisions and seeking new products and skills; Program: The agency recognizes the potential in healthcare for events to occur which may have a serious adverse outcome. It willingly participates in education in, identification of and reporting of sentinel events; - The agency management staff will utilize the process as established by CHAP (Community Health Accreditation Partners) if a sentinel event should be identified; the process includes: * Conducting a thorough and credible root cause analysis focusing on agency processes and system factors; * Creating, documenting and implementing a risk-reduction strategy and action plan that includes measuring the effectiveness of process/system improvements to reduce risks; * Reporting the sentinel event to the CHAP for inclusion in the sentinel event data base; and - Information on reviewable sentinel events from CHAP will be maintained in the agency documents file and updated on a regular basis. During an interview and observation on 08/31/2021 at 2:35 PM with the director of nursing/clinical manager stated and showed: - The agency did not have evidence of a QAPI program; - Stated: The agency changed the format of the QAPI program; - The agency reviewed charts of patients quarterly just to find patterns or things missing; - Because of short staffing and COVID, QAPI was done and nothing was documented; - The agency kept an eye on the STAR rating program; and - The agency has no formal QAPI program.

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 review of the agency's policy, observation and interview, the agency failed to put in place a program for screening visitors/non-employees who entered the home health agency office and patients prior to home visits for COVID-19 (pandemic infection) signs and symptoms. This deficient practice has the potential to affect the care and safety of all patients served by the agency. Findings included: Review of the agency's undated policy titled "Protocol for Seeing Patients for Home Health" showed: - When calling a patient for setting up an appointment, make sure to ask for COVID-19 related symptoms- fever, cough, shortness of breath, and body aches; - Ask if the patient has been exposed to anyone with COVID-19 related symptoms; - If suspected that a patient or family member was exposed to COVID-19, it should be reported to the home health office, and should be quarantined for 14 days and if the symptoms appear, contact their physician; and - Any patient who comes down with COVID-19 symptoms, should be guided to see the physician and quarantine, and should be reported to the Missouri Health Department. Review of the agency's policy titled "Exposure to Corona Virus (2019-nCoV): Disease Response and Management" dated 02/13/2020 showed: - Clinicians should assess patients based on the following: - Does the patient have fever or symptoms of lower respiratory infections such as shortness of breath or cough and has the patient traveled to mainland China within 14 days of symptom onset, or had close contact with a person confirmed with 2019-nCoV or under investigation for 2019-nCoV. The agency did not provide a COVID-19 specific policy for monitoring of visitors/employees who entered the agency. Observation on each day of the survey, 08/31/2021 through 09/02/2021 showed: - No signage on the entry door of the agency to advise visitors and staff of COVID-19 information; - No signage on the entry door of the agency to provide visitation restrictions and screening procedures; - A sign was in the lobby of the building where agency was located that stated to wear masks, but no signage posted on the agency door to wear masks; and - No screening procedures of staff or surveyors who entered the agency on all days of the survey. During an interview on 08/31/2021 at 2:35 PM, the director of nursing/clinical manager stated that: - Staff do not screen patients for COVID-19, they look at the hospital referral, and ask for COVID-19 test results if a test was performed; - The agency did not admit any patients with COVID-19; - The agency stopped screening staff for COVID-19 symptoms because all had been vaccinated; - No visitors enter the agency; - The agency do not screen patients prior to home visits other than when the referral is made because they accept no COVID-19 patients and have not had any COVID -19 patients; they stopped the screening a while ago; - Staff do educate patients/caregivers on COVID-19 and information is left in the home for the patient/caregiver.

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 policy review, clinical record review, and interview, the agency failed to ensure staff provided services as ordered by the physician in one (Record/Patient #4) of five full clinical records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled "Physician Orders" dated June, 2010 showed: - Policy: Physician orders will be obtained when indicated by patient need or change in patient's medical condition; all skilled services are provided under the direction of a physician. Review of the agency's undated policy titled "Job Description Medical Social Worker," showed: - Duties include but not limited to: Assess psychosocial status, collaborates with the physician and other members of the health team to develop a plan of care, and consultation and coordination of services with other disciplines. RECORD/PATIENT #4: Review of a physician order dated 06/10/2021 showed: - Social worker to evaluate for meals on wheels if patient is eligible. Review of a patient communication note dated 06/14/2021 showed: - Social worker not able to make it in to see the patient, as the patient did not answer his/her telephone call. Review of the clinical record showed: - The social worker did not document any other missed visits related to assisting the patient to receive meals on wheels; and - He/she did not document any visits to show the patient was assisted to receive meals on wheels if eligible. During an interview on 09/01/2021 at 4:00 PM, the director of nursing/clinical manager stated that: - The patient lived alone and all disciplines had to contact the patient's family member in order to get approval to see the patient; - The social worker was not able to get in touch with the family member, and a visit was not made to assess for eligibility for meals on wheels.

Org. had partial/extended survey CFR(s): 484.80(f)(3) Was subjected to an extended (or partially extended) survey as a result of having been found to have furnished substandard care (or for other reasons as determined by CMS or the state); or This ELEMENT is not met as evidenced by: Based on the results of this extended level survey, resulting in noncompliance with four Conditions of Participation: Patient rights; Comprehensive assessment of patients; Care planning, coordination of services and quality of care; and Organization and administration of services, the agency may not train or competency evaluate their home health aides for a period of two (2) years following the date of this survey. The restriction ends 09/02/2023.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on policy review, job description review, observation, and interviews, the agency failed to organize, manage, and administer it's resources to attain and maintain the highest practicable functional capacity, including providing optimal care when the agency failed to showed adequate governing body, administrative, and clinical manager oversight to patients resulting in five conditions of participation citations. The following standard level deficiencies were cited under this condition of participation: - Be responsible for all day to day operations of the home health agency (HHA), (G948); - Clinical Manager: One or more qualified individuals must provide oversight of all patient care services and personnel, oversight must include (G958); and - Assuring the development, implementation, and updates of the individualized care plan (G968); The cumulative effect of these systemic practices resulted in the agency's inability to ensure the patient's care needs would be met.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on current survey findings, administrator job description review, and interviews, it cannot be assured the administrator or designated alternate administrator has effectively assumed responsibility for the overall administration, supervisory functions, and overall operations of the home health agency. The agency failed to show the administrator or alternate administrator were responsible for all day to day operations of the agency. This deficient practice has the potential to affect all the patients receiving services from the agency. Findings included: This deficient practice led to the failure of the agency to comply with five Conditions of Participation: - § 484.50 Condition of Participation: Patient Rights; - § 484.60 Condition of Participation: Care Planning, Coordination of Services and Quality of Care; - § 484.65 Condition of Participation: Quality Assessment and Performance Improvement (QAPI); - § 484.102 Condition of Participation: Emergency Preparedness; and - § 484.105 Condition of Participation: Organization and Administration of Services. Review of the job description, in part, the undated CEO/Administrator showed: - Reports to the board of directors/shareholders; - Position summary: The CEO/administrator is responsible for the profitability, planning and overall administration of the organization. The CEO/administrator is accountable for all activities and departments. - Qualifications: * Bachelor's degree I business or management, MBA (Masters in Business Administration) and/or CPA (Certified Public Accountancy) preferred or six years' experience in management; * Five years in upper management; * Exhibits leadership skills; * Two to four years in home health care management experience; - Summary of job functions includes but not limited to: * Ensures that the numbers and qualifications of personnel available to provide services are sufficient to meet the medical, nursing, and therapy needs; * Ensures policies and procedures meet federal, state, local, and accrediting organization's regulations and standards; * Develops strategic and short term plans for the organizational development; and * Educates the community to the agency programs by interacting with numerous individuals and groups. Review of the undated job description for the Administrator showed: - Position summary: The administrator is responsible for the financial solvency, planning and overall administration of the organization. The administrator is accountable for all activities and departmental operations; - Qualifications include, but not limited to: * Registered nurse (RN) or having training and experience in health service administration and at least one year of supervisory or administrative experience in home health care or related health programs; * Exhibits leadership skills; * GED or high school diploma; - Summary of job functions include, but not limited to: * Ensures that the numbers and qualifications of personnel available to provide services are sufficient to meet the medical, nursing, and therapy needs of clients; * Ensures that policies and procedures meet federal, state, and accrediting organization's regulations and standards; * Implements policy and procedures; * Develops strategic and short term plans for organizational development; and * Educates the community to the agency programs by interacting with numerous individuals and groups. During an interview on 08/30/3031 at 2:20 PM, the administrator entered the agency, introduced himself as administrator and PT who saw patients in Illinois and Missouri, and that he/she supervised the day to day activities of both agency offices. He/she the owner/operator of the Missouri and Illinois agencies. The Illinois agency is not a branch office and had a separate Medicare provider number. During the initial entrance interview on 08/30/2021 at 2:25 PM, the CM/DON/alternate administrator stated that: - He/she and the administrator are the owner/operators of the Missouri and Illinois agencies. The Illinois agency is not a branch office and has a separate Medicare provider number; - He/she was the predesignated person to act in the absence of the administrator; On all days of the survey 08/30/2021 through 09/02/2021, the administrator was in Illinois and Missouri making home visits. Came into the agency only after seeing all patients who were scheduled for PT visits. On all days of the survey, 08/30/2021 through 09/02/2021, the CM/DON/alternate administrator was in the field making home visits and then came into the agency to assist surveyors.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on record review, home visit observation, and interviews, the home health agency failed to ensure that the clinical manager/director of nursing was available for oversight of all patient care services and personnel, assuring the patient's needs were continually assessed, and assuring the development, implementations and updates of individualized plans of care on three (Record/Patient #1, #2, and #3) of three home visits made. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy dated 06/2010 titled "Care Planning" showed: - The plan of care is based upon the physician's orders and encompasses the equipment, supplies and services required to meet the patient's needs; - At the time of the admission visit, the primary clinician develops the patient plan of treatment based upon the patient's identified needs and reviews it with the patient and family or caregiver(s); - Services to be provided will be based on the prioritized needs of the patient; - Care decisions and outcome development will be made as a result of the care planning process and analysis of assessment visit including but not limited to: * Identified patient problems and needs identified by the comprehensive assessment; * Interventions to be utilized to meet the patient goals and/or outcomes; and * Clinicians will inform the patient's physician of any changes which may indicate a need for change in the plan of treatment. . RECORD/PATIENT #1: Review of the plan of care (POC) dated 08/17/2021 through 10/15/2021 showed, in part, the following: - Diagnosis included unspecified diastolic (congestive) heart failure, hypertrophic osteoarthropathy (hypertrophic condition that is marked by clubbing of the fingers and toes, painful swollen joints, and periostitis and subperiosteal bone formation chiefly affecting the long bones), burn of unspecified degree of right lower leg, pressure-induced deep tissue damage of unspecified heel, unspecified wound of left great toe with damage to nail, laceration (cut) to left foot; - The POC did not include diabetes mellitus (abnormally high blood glucose/sugar levels); - The POC showed Metformin HCL (anti-diabetic medication) 850 mg (milligrams), one tablet twice daily; - The POC showed Levemir (long acting insulin to treat/control high blood sugar in adults with diabetes) subcutaneous 100 units/ml (milliliter) taking 10 units at bedtime daily; - The POC showed to instruct on signs and symptoms of hyperglycemia (high blood glucose levels), glucometer (measures how much glucose is in the blood) use and preparation and administration of diabetic medications ordered by the physician; - The POC did not include parameters for high blood glucose levels, or how often the patient was to check his/her blood sugars; - Durable medical equipment (DME) and supplies: cane, probe covers, exam gloves and walker; - The agency failed to list the glucometer under the DME and supplies; - Silver sulfadiazine (stops the growth of bacteria that may infect an open wound) external 1% 400 grams apply twice daily to effected area; - Menthol-zinc oxide (used to treat and prevent minor skin irritations) external apply to affected area twice daily; - The plan of care failed to show for both silver sulfadiazine and menthol-zinc ( topical medications applied to the skin) what specific areas of the body they were to be applied; - The POC showed the patient's left toe was swollen and inflamed, he/she had a cut on his/her heel and stubbed his/her left toe, the patient had been applying triple antibiotic on it and had it covered with a soiled bandage, the area was assessed, cleaned and new bandage was applied and new wound care supplies have been ordered for the patient; - The plan of care failed to show physician orders for treatment to the left toe and the left heel; - The POC showed skilled nurse to assess pain level; and - The POC failed to show pain parameters and when to report to the physician. ` ` During an interview on 08/03/2021 at 3:25 PM the clinical manager stated: - There was no diabetes listed on the first referral so he/she had to get a second referral; - He/she didn't think the patient was using the menthol-zinc oxide and silver sulfadiazine but during today's visit the patient said he/she was; - The clinical manager was confused to the type of treatment to the left toe and heel, the treatment frequency, and what the order was; - The patient can do his/her own blood sugar checks but he/she needs more care than he/she was getting right now; and - No further information was provided. RECORD/PATIENT #2: Review of the start of care OASIS (Outcome and Assessment Information Set, is a comprehensive assessment designed to collect information related a patient's plan of care in the home) dated 08/13/2021 showed: - Start of care (SOC) date: 08/13/2021; - Diagnoses included but not limited to: Unspecified heart failure, Type 2 diabetes mellitus (abnormally high blood glucose/sugar levels treat with medications), did not include stasis ulcers to bottom of right toe, wound to right small toe, and three wounds to the left lateral foot; - Did not include parameters for hyperglycemia (high blood glucose levels) or hypoglycemia (low blood glucose levels), monitoring of blood glucose levels, or when to notify the physician of abnormal levels; and - Did not include wound care interventions. Review of the POC dated 08/13/2021 through 10/11/2021 showed: - Diagnoses included but not limited to: Non-pressure chronic ulcer to foot, polyneuropathy (damage to multiple nerves outside of the brain and central nervous system that can cause pain, discomfort, and mobility difficulties), and Type 2 diabetes mellitus; - Skilled nurse (SN) to instruct patient/caregiver on wound care: - Wound care not documented; - SN to instruct on all aspects of diabetic management to include disease process, foot assessments, signs and symptoms of hypoglycemia and hyperglycemia, glucometer (machine to check blood glucose levels) use and preparation and administration of diabetic medications ordered by the physician; - Did not include parameters to contact physician of abnormally high or low blood glucose levels; and - Did not list wound care supplies in DME and supplies section of the POC. During an interview on 09/01/2021 at 4:00 PM, the director of nursing/clinical manager stated that: - Parameters for blood glucose levels for hypoglycemia and hyperglycemia should be listed on the POC; and - No other information provided. RECORD/PATIENT #3: Review of the physical therapy (PT) evaluation dated 08/27/2021, showed the following: - Medical diagnosis sequelae of cerebral vascular accident (stroke) and right hemiparesis (weakness); - PT diagnosis non ambulatory, impaired bed mobility and transfers, and weakness; - Patient has complained of pain at rest, reports pain in right hip and reports white skin spot on buttock; - Right hip pain relieved by Tylenol, gabapentin (anticonvulsant) and rest; - The patient and caregiver state the patient has a white skin spot on buttock and that they have received medication from the physician; and - Skin wound appearing on buttock, physician contacted regarding skin issue and physical therapy awaiting physician office to authorize a skilled nursing evaluation. Review of the physical therapy (PT) treatment plan (plan of care) dated 08/27/2021 failed to show the following: - Diagnosis; - Medications; - Oxygen saturation parameters and when to notify the physician; - Buttock wound treatment; - Instruction for positioning; - List of home exercises; and - The patient's right hip pain and interventions. The information was reviewed with the clinical manager on 08/31/2021 at 11:00 AM and 3:45 PM, he/she stated the PT evaluation is the plan of care. Staff read the PT evaluation note section for the plan of care. The physical therapy evaluation and treatment plan were sent to the physician for signature. No further information was provided. During an interview on 09/01/2021 at 12:14 PM, the PT stated the following: - He/she admitted the patient on 08/27/2021; - He/she called the physician to get a nurse out there; - The patient had pain everywhere, in his/her lower back, right hip and mostly joints; - He/she doesn't remember the patient rating his/her pain but it would be in his/her notes and it was part of the assessment; - The patient had a white spot on his/her upper buttocks, it was not open or broken down; - The patient hasn't been out of bed or turned and he/she provided education; and - The plan of care is created from the oasis assessment.

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on current survey findings with five condition level deficiencies and the job description for the clinical manager and director of nursing, it cannot be assured that the clinical manager/director of nursing has effectively assumed responsibility for the overall supervision and direction of skilled professional services and actively participates in all activities relevant to the professional services furnished and including assuring development, implementation, and updates to the individualized care plans; and to develop a QAPI program, emergency preparedness training, and infection control surveillance and monitoring for patients, staff, and visitors. Findings include: Based on current survey findings, the clinical manager/director of nursing (CM/DON) failed to: - Assure complete and accurate plan of care; - Assure reconciliation of medications were accurate; - Assure comprehensive assessments were completed within 48 hours of referral; - Assure treatments and services were provided with orders from physicians; - Assure all physician's orders were followed, evaluations completed, and all home visits made as ordered; - Assure discharge and transfer summaries were sent to physicians and other healthcare providers to ensure continuity of patient care; - Assure a QAPI (Quality Assurance and Performance Improvement) program was initiated and updated every two years as the pre-designated person authorized in writing by the administrator and the governing body to act in the absence of the administrator; - Assure the Emergency Preparedness program and training was completed as required by the CMS (Centers for Medicare and Medicaid Services) regulations; and - Assure that surveillance and monitoring of COVID-19 (a pandemic) was performed for staff and patients. Review of the undated job description for the clinical manager/director of nursing showed: - Reports to the administrator; - Position summary: Responsible for the overall supervision and direction of health care services. The DON shares responsibilities with the administrator for the agency's overall compliance with State and Federal guidelines and standards of nursing practice; - Qualifications: Must be a registered nurse with public health, home health care, or hospital background; and have at least one year of clinical experience; - Duties and responsibilities include but not limited to: * Supervise and direct all clinical services; * Promote, review, and evaluate the quality and appropriateness of patient care practices; * Revise nursing care plan for appropriateness and application of physician's plan of care; * Review and act to resolve all complaints made by patients/families regarding care provided relating to services, personnel, or policies; * Receive and act to resolve complaints from caregivers regarding policies and procedures; * Inform and confer with administrator on all patient, personnel, and service management needs and problems; * Participate in assigning personnel to patients based on patient need and physician's care plan; * Assign personnel responsibility according to their education, area of expertise, personnel preference, and patient needs; * Coordinate individual cases to need disciplines; * Coordinate and ensure that the patient is well serviced through the assignment of skilled services and personal caregivers whose skills and abilities meet their individual needs; * Evaluated patient for eligibility to home health services level of care need; * Provide and oversees initial and ongoing in-service education and training for all nursing staff; * Assist administrator in ensuring adequate orientation of all staff; * Consult with physicians when necessary to ensure and maintain safe, efficient, and quality of patient care; and * Participate in quality improvement (QAPI) activities as required. During the initial entrance interview on 08/30/2021 at 2:25 PM, the CM/DON stated that: - He/she and the administrator are the owner/operators of the Missouri and Illinois agencies. The Illinois agency is not a branch office and has a separate Medicare provider number; - He/she was the predesignated person to act in the absence of the administrator; - He/she was the CM/DON; - He/she was in charge of QAPI, infection control and emergency preparedness; - Nursing and therapy were services the agency had trouble staffing; - Nursing was the qualifying service for Medicare; and - Physical therapy (PT) and occupational therapy (OT) are contracted employees. During an interview on 08/31/2021 at 2:30 PM, the CM/DON stated that: - Because of COVID -19, the agency was short staffed of nurses, PT, and OT; no one wants to work; - The agency did not hire home health aides; - He/she was the only full time nurse, there is a licensed practical nurse (LPN) but he/she was not full time, the administrator was a fulltime PT, other PT, OT, and speech therapy (ST) staff are contracted staff, and the master social worker (MSW) was agency staff; - The agency had no official QAPI program due to COVID-19 and short staffing; - Orders from physicians are late returning signed and difficult to obtain orders often from physicians; agency has lost physician's because too many orders, requests, information faxed to the physicians; due to short staffing, not able to go to physician's offices to get orders signed; - The agency has another home health office in Illinois, it is not a branch office and has a separate Medicare provider number; - He/she and the administrator cover both the Missouri and Illinois offices and patients; - They are spread thin due to COVID-19 and not able to find staff to hire; - The Illinois agency is busier than the Missouri agency and the staff see more patients in Illinois; - The Illinois agency has no full time staff except him/her and the administrator/PT; - Some staff have dual licenses and can work in both Missouri and Illinois; - The CM/DON is responsible to obtain referral orders - If PT or OT cannot complete the initial assessment timely, they are expected to notify the office or CM/DON and the CM/DON is not always available to be notified; - Staff should then notify the office and the office personnel send out a sticky note that informs the CM/DON that the evaluation could not be completed within 48 hours; - The physician would expect the evaluation to be completed within 48 to 72 hours; - Insurance companies also cause the lateness of evaluations because they can take days to weeks to give the agency approval; - He/she in serviced staff on COVID-19 but no other community drills or table top exercises were done since prior to COVID-19; and - COVID-19 conference call training on 03/12/2020 was canceled by the presenters, so not able to attend; - Only provided in-service for COVID 19 for staff in July, 2020 and June, 2021; - No community based exercises documented in 2018 or 2019; - Attempted to join the Coalition for EP on 02/05/2020 but the drill was canceled on 03/10/2020; and - No other training, drills provided for staff.

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 policy review, clinical record review and interview, the agency failed to ensure a complete comprehensive discharge summary containing relevant information was sent to the primary care practitioner or other health care professional who will be responsible for providing care to the patient after discharge within five business days of the patient's discharge for one (Record/Patient #6) of two discharge records reviewed and failed to ensure a transfer summary was sent to the receiving health care facility within two business days of becoming aware of an unplanned transfer in one (Record/Patient #4) of five full records reviewed. This deficient practice has the potential to affect all patients served by the agency. Findings included: Review of the agency's policy titled "Transfer and Discharge of Services" dated June, 2010 showed: - Policy: The patient and/or family member as well as the primary physician, should participate in discharge planning and be informed about the agency's decision to discharge, reduce or transfer services; - The receiving organization is provided with relevant written or verbal information within 72 hours of transfer; - All communication with the receiving facility is to be documented in the clinical record; - Transferring information will include current medical status of patient, care and treatment services received, a completed list of the patient's medications, relevant laboratory results, the presence of an active infection and caregiver information or assistance the patient receives at home; - Transfers to hospital settings will be coordinated with the designated patient liaison for the facility, if possible, and clinical staff members involved in the patient's care; - Transferring information will include current medical status of patient, care and treatment services received, a completed list of the patient's medications, relevant laboratory results, the presence of an active infection and caregiver information or assistance the patient receives at home; - Relevant information to be included when discharged, transferred, or referred to another organization should include reason for discharge or transfer, physical and psychosocial status, summary of the care/service provided and progress toward achieving goals, instruction and/or referrals provided to the patient, and a complete list of medications; - Information will be documented on appropriate discharge/transfer forms and will be completed within 72 hours; and - A copy will be forwarded to the attending physician at his/her request. RECORD/PATIENT #6: Review of a communication note dated 07/13/2021 showed: - Patient admitted to hospital, broke his/her hip on 07/08/2021; - Transferred to in-patient rehab per spouse; - Spoke with spouse on 07/13/2021; and - Physician notified at this time. Review of a discharge summary and order dated 07/28/2021 showed: - Patient suffered a fall on 07/07/2021 and was hospitalized; - Now discharged from skilled home health care services; - The discharge summary was faxed to the attending physician on 07/28/2021, 20 days after discharge; and - No documentation found that summary was sent to the hospital or in-patient rehab assuming care of the patient. RECORD/PATIENT #4: Review of occupational therapy (OT) discharge summary dated 03/04/2021 showed: - No documentation of a date of when the discharge summary was faxed to the attending physician; and - Signed by the attending physician on 06/10/2021, approximately three months after discharge from OT services. Review of a transfer assessment dated 03/11/2021 showed: - Transferred to in-patient facility; - Medication intervention: There were no potential clinically significant medication issues identified since the start of care/resumption of care (SOC/ROC) or patient not taking any medications; - Patient/caregiver drug intervention education since SOC/ROC: Yes; - Used hospital emergency department with hospital admission; - Reason for emergent care: Unknown; - In-patient facility: Hospital; - No reasons marked for hospitalization; - Date of transfer: 03/11/2021; and - No documentation of when the transfer information was sent to the receiving hospital/facility. Review of a transfer assessment dated 03/30/2021 showed: - Transferred to in-patient facility; - Medication intervention: There were no potential clinically significant medication issues identified since the start of care/resumption of care (SOC/ROC) or patient not taking any medications; - Patient/caregiver drug intervention education since SOC/ROC: Yes; - Used hospital emergency department with hospital admission; - Reason for emergent care: Unknown; - In-patient facility: Hospital; - Unknown reason for hospitalization; - Date of transfer: 03/30/2021; - No documentation of when the transfer information was sent to the receiving hospital/facility. Review of a physical therapy (PT) discharge summary and order dated 04/02/2021 showed: - Patient attended 12 PT sessions since the SOC and missed two sessions; patient hospitalized several times during the period, and no skilled services identified at this time; - No documentation of a date of when the discharge summary was faxed to the attending physician; and - Signed by the attending physician on 06/10/2021, approximately two months after discharge from PT services. During an interview on 09/01/2021 at 10:32 AM, the director of nursing/clinical manager stated that: - Staff send the transfer summary only to the physician; - Staff do not send discharge summaries to hospitals or other entities, just sent to the physician for notification of discharge or transfer.