Every finding on record at Crown Home Health Agency, Inc.

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 1/11/24. Standard Level deficiencies cited. Abbreviations: PM = afternoon/evening COVID-19 = Coronavirus Disease of 2019

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness Program and staff interview, it was determined the Agency failed to conduct emergency exercises as required. This has the potential to affect Pts. that receive services and Agency staff. Findings include: 1. The Emergency Preparedness Program last updated in 2023 was reviewed on 1/9/24. The Program contained documentation the Agency conducted Fire Drills on 12/8/20, 12/6/21, 12/8/21, 12/9/22, and 11/21/23. The Program lacked documentation the Agency had conducted a full-scale exercise, or an individual facility-based exercise, and/or had activated the Agency's Emergency Program since the full-scale exercise activation in 2019 for COVID-19. 2. During an interview with the Agency's Back-up Administrator and Director of Nursing on 1/9/24 at 1:30 PM, both confirmed the Agency failed to conduct emergency exercises as required.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 1/11/24. Standard Level deficiencies cited. Abbreviations: # = number AM = morning GM = gram(s) E = Employee PO = by mouth SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care mg/MG = milligram(s) PM = afternoon/evening Pt./ Pts. = Patient/Patients PT = Physical Therapy/Therapist OT = Occupational Therapy/Therapist

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 a review of the Agency's Pt. admission folder, observation during home visits, clinical record review and staff interview, it was determined the Agency failed to provide information regarding the Administrator and their contact information. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Pt. admission folder was reviewed on 1/8/24. The folder lacked documentation identifying the Administrator's name, address and phone number for the Pt. and/or legal guardian to contact. 2. The following home visits were conducted on 1/9/24 from 11:00 AM to 1:15 PM: Pt. #1. SOC 12/12/23. Pt. #2. SOC 10/20/23. Pt. #3. SOC 10/20/23. During the home visits, the Pt. admission folders were observed and lacked the name of the Administrator, their address and phone number. 3. The clinical records of the following Pts. were reviewed from 1/8/24 to 1/9/24: Pt. #1. SOC 12/12/23. Pt. #2. SOC 10/20/23. Pt. #3. SOC 10/20/23. Pt. #4. SOC 12/14/23. Pt. #5. SOC 10/4/23. Pt. #6. SOC 6/6/23. Pt. #7. SOC 8/1/23. The records lacked documentation the Agency had provided the name of the Administrator, their address and phone number. 4. During interviews with the Back-up Administrator and Director of Nursing on 1/9/24 at 1:30 PM, both confirmed this was the admission folder used for all Pts. admitted to this Agency, and that the Agency failed to provide information regarding the Administrator.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on review of the Agency's Pt. admission folder, observation during home visits, clinical record review and staff interview, it was determined the Agency failed to provide Pts. information regarding the Agency's transfer and discharge policies. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The Pt. admission folder was reviewed on 1/8/24. The folder lacked documentation of the Agency's transfer and discharge policies. 2. The following home visits were conducted on 1/9/24 from 11:00 AM to 1:15 PM: Pt. #1. SOC 12/12/23. Pt. #2. SOC 10/20/23. Pt. #3. SOC 10/20/23. During the home visits, the Pt. admission folders were observed, and lacked documentation the Agency had provided Pts. information, regarding the Agency's policies pertaining to transfer and discharge. 3. The clinical records of the following Pts. were reviewed from 1/8/24 to 1/9/24: Pt. #1. SOC 12/12/23. Pt. #2. SOC 10/20/23. Pt. #3. SOC 10/20/23. Pt. #4. SOC 12/14/23. Pt. #5. SOC 10/4/23. Pt. #6. SOC 6/6/23. Pt. #7. SOC 8/1/23. The records lacked documentation the Agency provided Pts. information, regarding the Agency's policies pertaining to transfer and discharge. 4. During interviews with the Back-up Administrator and Director of Nursing on 1/9/24 at 1:30 PM, both confirmed the Pt. admission folder reviewed is used for all Pts. admitted to this Agency, and that the Agency failed to provide Pts. information regarding the Agency's transfer and discharge policies.

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 observation and interviews during home visits, clinical record reviews, and staff interview, it was determined the Agency failed to ensure the medications in the PsOC are accurate. This was found in 2 of 7 (Pts. #2 and 3) clinical records reviewed. Findings include: 1. Pt. #2 was admitted to home health services on 10/20/23 with the diagnoses of Bilateral Primary Osteoarthritis of Knee, Type 2 Diabetes Mellitus with Lumbar Region Diabetic Polyneuropathy, and Mixed Hyperlipidemia. A home visit was conducted on 1/9/24 with the Director of Nursing. During the home visit, the patient's medications were observed, and an interview was conducted with the patient's caregiver. Observed the prescription bottle labeled "Atorvastatin 40 mg once daily by mouth date filled 12/18/23," the prescription bottle labeled "Gabapentin 300 mg capsule once daily by mouth dated filled 12/6/23," the prescription bottle labeled "Meclizine 12.5 mg 2 tablets once daily by mouth as needed for dizziness date filled 12/6/23," and "Vascepa 1 GM capsule Take 2 times a day date filled 11/20/23." The clinical record was reviewed on 1/9/24 and included a Physician order dated 12/6/23 which contained, "Medication update: Gabapentin 300 MG oral capsule 1 once daily PO by mouth" and signed by the physician on 1/2/24. The POC effective 12/19/23 was inaccurate to include Atorvastatin 20 MG, and lack Gabapentin, Meclizine and Vascepa. 2. Pt. #3 was admitted to home health services on 10/20/23 with the primary diagnosis of Type 2 Diabetes with Diabetic Autonomic (Poly) Neuropathy. The clinical record was reviewed on 1/9/24. A home visit was conducted on 1/9/24 with the Director of Nursing and E#5. During the home visit, the patient's medications were observed, and interviews were conducted with the Pt., Director of Nursing and E#5. Observed the prescription bottle labeled "Daily-Vite Take 1 tablet everyday by mouth date filled 11/13/23. Other medications observed included: Turmeric Curcumin, the Pt. stated 1 capsule is taken once daily by mouth for the past 3 months; Probiotic 100 million organisms, the Pt. stated 1 tablet is taken at night by mouth for the past 3 months; and Zyrtec 10 mg per tablet, the Pt. stated 1 tablet is taken twice a day by mouth, the Director of Nursing stated the Pt. had been taking Zyrtec for the past 3 to 4 weeks. The clinical record was reviewed on 1/9/24 and included the POC effective 12/19/23 which lacked: Daily-Vite, Turmeric Curcumin, Probiotic and Zyrtec. 3. During an interview with the Back-up Administrator and Director of Nursing on 1/9/24 at 1:30 PM, both confirmed the Agency failed to ensure the medications contained in the PsOC were accurate.

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 clinical record review and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 1 of 2 (Pt. #7) closed/discharged clinical records reviewed. Findings include: 1. Pt. #7 was admitted to home health services on 8/1/23 with the primary diagnosis of Essential (Primary) Hypertension. The clinical record was reviewed on 1/8/24. The record contained SN, OT, PT assessments and visit notes indicating services were provided from 8/1/23 to 11/17/23. The "SN Discharge Summary" dated 11/21/23 included documentation the Pt. was transferred to the hospital and discharged from the Agency. As of 1/8/24, the Agency lacked any documentation indicating a copy of the "SN Discharge Summary" was sent to the Physician. 2. During an interview with the Back-up Administrator and Director of Nursing on 1/9/24 at 1:30 PM, both confirmed the Agency lacked any record that a copy of the Discharge Summary was sent to the Physician.

EP Training Program CFR(s): 484.102(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 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: . A. Based on review of Agency's Emergency Preparedness Disaster plan and staff interview, it was determined the Agency failed to conduct staff training relative to the Agency's Emergency Preparedness Plan. Findings include: 1. The Agency's undated Emergency Preparedness Disaster Plan was reviewed on 02/09/21 at 11:00 AM. The Agency's Emergency Operations Plan (EOP) date October 2017 documented "Training and Testing: ....provides training to all staff, vendors and volunteers ....All new staff will receive training on emergency preparedness policies at onboarding and continue to receive training annually ...." The plan lacked documentation that the Agency conducted staff training in 2018, 2019 and 2020 pertaining to the Emergency Preparedness Disaster Plan. 2. During an interview with the acting Administrator on 02/10/21 at 12:00 PM, the acting Administrator confirmed the Agency failed to provide staff training regarding the Emergency Preparedness Disaster Plan.

Recertification survey completed. Standard level deficiencies cited. A Focused Infection Control Survey (FIC) was conducted on 02/11/2021. Crown Home Health Agency was in compliance with the requirements for Infection Control for COVID-19. Identification of abbreviations: lbs = pounds POC = Plan of care PT = Physical Therapy Pt./Pts. = Patient/patients RN = Registered Nurse SN= Skilled Nurse SOC = Start of care wk = Week

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: . A. Based on clinical records review, Agency practice and staff interview, it was determined that the Agency failed to ensure that the Aide supervision was conducted every 14 days by the RN. This was found in 1 of 1 clinical records reviewed with Aide Services. (Pt. #7) Findings include: 1. Pt. #7 SOC 09/29/2020 Diagnoses: Essential Hypertension, Alzheimer's Disease and Unspecified visual loss. The clinical record was reviewed on 02/09/2021 at 1:30 PM. The clinical record contained Aide visit notes 2 times a week from week 2 to week 6, for certification period 09/29/2020 to 11/17/2020. The same record contained weekly RN visits beginning week 1 to week 6. The record lacked documentation that the Aide was supervised by the RN from week 1 to week 6 of certification period (35 days). 2. During the entrance interview on 02/09/2021 at 9:30 AM the acting Administrator stated that Agency practice is that Aides are supervised every 14 days by the RN. 3. Findings of Aide not supervised by the RN every 14 days according to regulation and Agency practice was confirmed during an interview with the acting Administrator on 02/10/2021 at 2:30 PM.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician orders; This ELEMENT is not met as evidenced by: . A. Based on the clinical records review, home visit observations and staff interview, it was determined that the clinical record was lacking current/accurate clinical notes and plans of care. This was found in 3 of 7 records reviewed (Pts. #1,5 and 2). Findings include: 1. Pt. #1 SOC 10/01/20 Diagnoses: Parkinson and Dementia. The clinical record was reviewed on 02/09/21 at 11:00 AM. The record lacked current SN visit notes after 01/28/21. During the interview with the Agency Supervisor, on 02/10/21 at 11:30 AM, it was stated that the SN visit was conducted and the notes are not completed in the clinical record. The same record also included a SN visit note dated 01/28/2021 with a weight loss of 8 lbs within 1 week (week #9) and a SN visit note dated 01/31/2021 with a weight gain of 7 lbs in one week (recert-week #1). The record lacked documentation of the communication with the physician. During the interview with the Agency Supervisor, on 02/10/21 at 11:30 AM, it was stated that some of the weight-assessments in the SN visit notes were a documentation error. 2. Pt. #5 SOC 01/07/21 Diagnoses: Type 2 Diabetes Mellitus without complications and Essential Hypertension . The clinical record was reviewed on 02/09/21 at 11:30 AM. The record lacked a plan of care with the patient's current address. The record included a plan of care dated 01/07/21 with the patient's incorrect home address. This error was observed during the scheduled home visit for 02/10/21 at 1:00 PM. During the interview with the Agency Supervisor, on 02/10/21 at 1:50 PM, it was stated that the current address was documented on the patient's profile, instead of the plan of care. The same clinical record also included a visit note dated 01/12/2021 with a weight loss of 18 lbs within 1 week and a visit note dated 01/20/21 with a 27 lbs weight loss within 2 weeks. The record lacked documentation of the communication with the physician. During an interview with the Agency Supervisor, on 02/10/21 at 11:30 AM, it was stated that some of the weight-assessments in the SN visit notes were a documentation error. 3. Pt #2 SOC 01/16/21 Primary Diagnosis: Hypertension. The clinical record was reviewed on 02/10/21 at 9:00 AM. The record included a Physician order dated 01/22/21 for the certification period of 1/16/21-03/16/21 which required: " .... PT frequency of 1 wk 1, 2 wk 2, 1 wk 1 ...." The record contained a PT visit dated 1/25/21 for week of 1/24 - 1/30/2021 (week 3). The record lacked any other PT visit note for the week. 4. During interview with Administrator and Agency Supervisor on 02/10/21 at 12:00 PM, the acting Administrator stated that visit documentation should have been submitted within a week. The acting Administrator and Agency Supervisor confirmed the visit was made and that staff did not submit documentation within a week, as required by the Agency. 5. The findings of the clinical records lacking current/accurate clinical notes and plans of care were confirmed during interviews with the Acting Administrator and Agency Supervisor bettween 11:30 AM and 12:00 PM.