Every finding on record at D & P Homecare, Inc

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification Survey (4F270-H-1) at the above-named Home Health Agency (HHA) from 08/10/22 to 08/15/22 resulted in substantial compliance with the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22 and the following standard-level deficiencies cited.

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 interviews and document review, the facility failed to develop and maintain an emergency plan, to include facility-based and community-based risk assessments to assist the facility in addressing the needs of its patient population in the event of an emergency. The failed practice had the potential to affect all 150 patients. Findings Include: Review of an undated facility policy titled, “Emergency Preparedness Policy and Procedure” showed the purpose of the policy was to maintain agency operations and/or mitigate service disruption during untoward or emergency situations that impacted the internal and external agency environment. The policy further showed, as part of emergency preparedness and response plan development, the agency would conduct a risk assessment to identify the potential disasters from natural and man-made causes most like to occur in the agency's service area. During an interview on 08/11/22 at 2:30 PM, when asked for the facility's emergency plan, Staff A, Administrator, stated she could not locate any emergency preparedness documentation. She stated she recalled that the facility conducted community-based drills at a nursing home, and she believed the documentation was at the nursing home. Staff A indicated she would try to obtain the documentation. During a follow-up interview on 08/15/22 at 8:45 AM, Staff A provided a copy of the facility’s emergency preparedness policy but stated the facility did not have an emergency plan.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification survey (4F270-H1) conducted at the above-named Home Health Agency (HHA) from 08/10/22 to 08/15/22 resulted in noncompliance with one Condition of Participation, 42 CFR 484.65, Quality assessment and performance improvement (QAPI), respective to applicable CoP under 42 CFR 484, Subpart A through C and the following standard-level deficiencies cited.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review, document review, and interview, the facility failed to ensure physical therapy services were provided as per the physician-ordered plan of care and that the physician was consulted regarding the missed services for 1 (Patient 8) of 10 patients whose plans of care were reviewed. The failed practice had the potential to cause Patient 8 to be delayed in reaching therapy goals. Findings Include: Review of the facility's document titled, "Contract to Provide Therapies" showed contract employees were responsible for scheduling visits with the patient, in accordance with the physician’s plan of treatment and the needs of the patient. The contract also showed that any variance in the frequency and/or duration of visits or services must be authorized by signed physician's orders. Review of an Outcome and Assessment Information Set (OASIS) start of care assessment, dated 06/08/22, showed Patient 8's primary diagnosis establishing the need for home health services was a right humeral fracture (fracture of the humerus – the long bone in the upper arm). The assessment indicated the patient required supervision or touching assistance with transfer and walking ten feet, with a discharge goal to be independent with these activities. Additionally, the patient required substantial/maximal assistance with picking up an object from the floor and had a discharge goal to complete this activity with only set-up or clean-up assistance. Review of a "Physical Therapy Plan of Care," electronically signed by the Advanced Practice Registered Nurse (APRN) on 06/27/22, showed that Patient 8 was to receive physical therapy visits once per week for one week, then twice weekly for three weeks, then once weekly for one week. Physical Therapy was to perform balance training; therapeutic exercises to restore strength and mobility; and instruction on use of adaptive equipment, safety, pain management. Review of a "Missed Visit" form, dated 08/04/22 and digitally signed by Staff F, Physical Therapy Assistant (PTA), revealed the physical therapy visit scheduled for 08/04/2022 was missed. The form did not document a reason for the missed visit; however, the "Comments" section indicated, "scheduling error." Additionally, the form showed the physician's office was not notified and no order was generated related to the missed visit. During an interview on 08/11/22 at 3:42 PM, Staff A, Administrator, stated she was notified of the missed visit "today [08/11/22]." She stated apparently, the PTA went on vacation and did not attempt to have another Physical Therapist (PT) or PTA cover visits while she was gone. Per the Administrator, the PTA missed the visit because she tried to cluster all the visits into two days before leaving for vacation, and then attempted to cluster them again upon her return to work.

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 facility policy review and interview, the facility failed to develop, implement, evaluate, and maintain an effective, ongoing, home health agency (HHA)-wide, data-driven Quality Assessment and Performance Improvement (QAPI) program. Findings included: Review of the facility’s policy titled, “Organizational Quality Assessment and Performance Improvement (QAPI) Program,” revised 01/01/2018, indicated the purpose of the HHA’s Quality Assessment and Performance Improvement (QAPI) program shall be designed to: 1. Delineate expectations and plan and manage processes to measure, assess and improve the HHA’s governance, management, clinical and support activities; 2. Promote positive patient outcomes through the application of optimal patient care, treatment and services based on clinically sound principles and current knowledge; 3. Identify, on an ongoing basis and in a coordinated and collaborative manner, areas for improvement in the quality of care, treatment and services; and 4. Evaluate, monitor, improve and resolve areas of concern. The policy further indicated the HHA’s QAPI plan shall be evaluated at least annually and revised as necessary. During an interview on 08/11/2022 at 2:30 PM, Staff A, Administrator, stated she could not find any QAPI program documentation but stated she would continue to look and would try to obtain the documentation. In a subsequent interview on 08/15/2022 at 8:45 AM, Staff A, the Administrator stated she did not have any current QAPI program data. Staff A stated the HHA had not utilized the QAPI Program since 2017.

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on interviews and facility document review, the Home Health Agency failed to maintain a Quality Assurance and Performance Improvement (QAPI) program that measured, analyzed, and tracked quality indicator data to monitor the effectiveness and safety of patient services. The failed practice had the potential to affect all 150 patients. Findings Include: Review of the facility’s policy titled, “Organizational Quality Assessment and Performance Improvement (QAPI) Program,” revised 01/01/18, showed the home health agency's (HHA's) QAPI program shall be designed to delineate expectations and plan and manage processes to measure, assess and improve the HHA’s governance, management, clinical and support activities; promote positive patient outcomes through the application of optimal patient care, treatment and services based on clinically sound principles and current knowledge; identify, on an ongoing basis and in a coordinated and collaborative manner, areas for improvement in the quality of care, treatment and services; and evaluate, monitor, improve and resolve areas of concern. The policy also showed the HHA’s QAPI plan was to be be evaluated at least annually and revised as necessary. During an interview on 08/11/22 at 2:30 PM, when asked for documentation of the agency's QAPI program, Staff A, Administrator, stated she could not find any QAPI program documentation but that she would continue to look for the documentation. In a follow-up interview on 08/15/22 at 8:45 AM, Staff A provided the agency's QAPI policy and stated she did not have any current QAPI program data.