Every finding on record at Day-By-Day Staff Relief, LLC

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (5F982-H1) at the above-named Home Health Agency (HHA) from 04/25/23 to 04/27/23 resulted in the following deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on review of the Emergency Plan (EP) and staff interview, the Home Health agency failed to develop an agency-based and a community-based risk assessment prior to developing the agency's emergency plan. Failure to develop emergency plans based on community-based risk assessment has a potential risk and may cause harm to the patients and staff during an emergency if specific needs of both the patient and staff are not identified as part of the EP plan. Findings Include: On 4/25/23 between 11:00 am and 2:30 pm, during the interview and review of the Emergency Preparedness Plan with the Administrative Director, it was observed the facility did not have a plan which included a Risk Assessment based on an, "All Hazards Approach." The Administrative Director was present and acknowledged the findings.

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), §485.542(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 Emergency Plan and interview, the Home Health agency failed to provide in its emergency preparedness plan, documentation of efforts to contact the local, regional, State, or Federal emergency preparedness officials, and include a process for cooperation and collaboration with the local, regional, State, or Federal emergency preparedness officials. This failure could result in inadequate planning and preparedness for an emergency event. Findings Include: On 4/25/23 between 11:00 am and 2:30 pm, during the interview and review of the Emergency Preparedness Plan with the Administrative Director, it was observed the facility's emergency preparedness plan did not have documentation of efforts to contact the local, regional, State, or Federal emergency preparedness officials, and include a process for cooperation and collaboration with the local, regional, State, or Federal emergency preparedness officials. The Administrative Director was present and acknowledged the findings.

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), §485.542(b)(6), §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 review of the Emergency Plan and interview, the Home Health agency failed to ensure emergency preparedness policies and procedures included the use of volunteers during an emergency. This failure has the potential to place patients at risk for unmet needs during an emergency. Findings Include: On 4/25/23 between 11:00 am and 2:30 pm, during an interview and review of the Emergency Preparedness Plan with the Administrative Director, it was observed the facility's emergency preparedness plan did not have a policy in place which addressed the use of volunteers. The Administrative Director was present and acknowledged the findings.

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), §485.542(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 Emergency Plan and interview the Home Health agency failed to develop, establish and maintain comprehensive Emergency Preparedness Program policies and procedures for the agency's written communication plan. This failure has the potential to place patients at risk for unmet needs during an emergency. Findings Include: On 4/25/23 between 11:00 am and 2:30 pm, during the interview and review of the Emergency Preparedness Plan with the Administrative Director, it was observed the facility's emergency preparedness plan did not have a documented communication plan which contains how the facility coordinates patient care within the facility, across healthcare providers, and with state and local public health departments. The Administrative Director was present and acknowledged the findings.

On behalf of the Centers for Medicare and Medicaid Services (CMS), an unannounced on-site Recertification survey (iQIES 5F982-H1) at the above-named Home Health Agency from 04/25/23 to 04/27/23 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review, policy review and interview, the Home Health Agency (HHA) failed to ensure coordination of care to assure blood sugar readings out of prescribed parameters were communicated to the physician for 2 or 2 patients (Patients 8 and 9) and failed to ensure care was coordinated to assure newly identified patient needs were coordinated with the supervisor or physician for 2 of 2 patients (Patients 8 and 10). These deficient practices have the potential to affect patient safety and to place patients at risk for altered treatment outcomes. Findings Include: Review of a HHA policy titled, "Service Delivery-Coordination of Services: S05”, Revised 10-08-2021 showed the policy purpose was to establish guidelines for communication and liaison between care providers that confirmed continuity, consistency, efficiency, and appropriateness of service delivery; supported objectives outlined in the plan; confirmed that documentation in the clinical record; showed coordination of services; and assured communication with all physicians involved in the plan of care. The policy showed professional staff coordinate services with the physician and promptly alert the physician to any changes that suggested a need to modify the plan of care. The policy showed the agency established procedures regarding admission, planning and ongoing provision of services, assignment and supervision of staff, documentation, and communication, which promoted coordination of services. The policy showed that staff implement actions, reflect coordination that includes interdisciplinary communication, reporting, education, and supervision; notification of physicians regarding changes in patient condition or needs. The policy showed licensed professional staff notify the physician, patient and family, other staff of significant events or revisions in the plan. Patient 8 Review of Patient 8’s Home Health Certification and Plan of Care (POC) for the Certification Period of 03/20/23 to 05/18/23 showed a primary diagnosis of Urinary Tract Infection, with Chronic Kidney Disease, Neuromuscular Dysfunction of the Bladder, Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Type 2 Diabetes Mellitus with Diabetic Neuropathy. The POC showed skilled nursing services, physical therapy, occupational therapy, and speech therapy were to provide services to the patient. The POC ordered the licensed professional to report vital signs falling outside of the established parameters, including Fasting/Random Blood Sugar result less than 70 or greater than 180 (FBS 180, RBS 180). Review of the Visit Note Report, dated 03/31/23, completed by Staff B, Physical Therapy Assistant (PTA), showed the patient reported she felt like she had a UTI, stated she had one in March as well and the patient’s overall activity and exertion levels were decreased with difficulty walking outside; fatigued quickly. Staff B documented a urine sample cup and hat were provided to the daughter for urine collection and take to lab. The Visit Note Report care coordination, used to document all details of care coordination related to the patient visit, including names and credentials of who care was coordinated with showed: NA (not applicable). There was no documentation to support Staff B, PTA reported findings to the Physical Therapy Supervisor or physician regarding patient reported symptoms of urinary tract infection, decreased activity and exertion levels and instructions provided to the patient and daughter. Review of the Visit Note Report, dated 04/03/23, completed by Staff C, Certified Occupational Therapy Assistance (COTA) showed the patient stated she had been feeling weak over the weekend and unsteady at times and will be starting a new antibiotic. Staff C documented need and education provided for patient to increase water intake as patient reported another UTI. Patient stated that she does not like to drink water and the patient stated she will start a new antibiotic today. Staff C documented not applicable (NA) to any new or changed meds identified. The Visit Note Report directed the writer (Staff C) to document concerns/new meds/med changes and to notify supervising therapist. There was no documentation to support Staff C, COTA reported findings to the Occupational Therapy Supervisor or physician about feelings of weakness reported by the patient, report of urinary tract infection with positive Urine Analysis, nor new antibiotic medication. Review of the Visit Note Report, dated 04/05/23, completed by Staff C, COTA showed the patient stated she had not had a BM (Bowel Movement) in approximately 5 days and reported pain in abdomen and constipation. Staff C documented she encouraged the patient to increase water intake and consider increasing her OTC (over the counter) stool softener. The Visit Note Report care coordination, used to document all details of care coordination related to the patient visit, including names and credentials of who care was coordinated with, showed the care plan was coordinated with the patient’s daughter. There was no documentation to support Staff C, COTA reported findings to the Occupational Therapy Supervisor or the physician about abdominal pain related to constipation, instructions to the patient/daughter on medications to consider nor the report by the patient of not having a bowel movement in approximately 5 days. Review of the Visit Note Report dated 04/12/23, by Staff D, Registered Nurse (RN) showed the patient’s “actual blood sugar testing range over the past two weeks” was from 126 to 235 (a procedure that measures the amount of glucose/sugar in the blood). The Visit Note Report showed the patient reported completion of an antibiotic but daughter able to still smell an odor. The report showed the patient /daughter were unsure if it was from the sample sitting there for a period of time before emptied with instruction to patient and daughter to continue to monitor urine and if odor was worse, to contact the physician and drop off another urine sample. There was no documentation to support Staff D, RN coordinated with and reported findings to the physician, regarding the patient’s blood sugar testing out of the acceptable parameters ordered on the Plan of Care for a Fasting/Random Blood Sugar result less than 70 or greater than 180 (FBS 180, RBS 180). There was no documentation to support the physician was contacted regarding the patient’s reported, continued odor in urine, following completion of antibiotics. Review of the Visit Note Report, dated 04/18/23, completed by Staff E, Speech Therapist (ST) showed the patient reported feeling very tired and fatigued, stating she didn’t know why she was feeling so tired. The patient reported she had a UA completed and was found to be positive for UTI yesterday and awaiting results of the culture before starting and antibiotic. The patient reported increased difficulty with word finding since she was more fatigued. There was no documentation to support Staff E, ST coordinated with and reported findings to the physician, regarding the patient’s report of a positive UA for a UTI to clarify pending UA culture results, the plan for antibiotics and the patient’s reported symptoms. Review of the Visit Note Report, dated 04/19/23, completed by Staff F, Licensed Practical Nurse (LPN) showed the patient’s “actual blood sugar testing range over the past two weeks” was from 86 to 256 and that the patient did not check blood sugar this AM due to not having a sensor in place since the prior day. The Visit Note Report showed the patient was using coconut oil for constipation. There was no documentation to support Staff F, LPN coordinated with and reported findings to the registered nurse, the physician about the patient using coconut oil for constipation, nor the patient’s blood sugar testing out of the acceptable parameters ordered on the Plan of Care for a Fasting/Random Blood Sugar result less than 70 or greater than 180 (FBS 180, RBS 180). Patient 9 Review of Patient 9’s Home Health Certification and Plan of Care (POC) for the Certification Period of 03/27/23 to 05/25/23 showed a primary diagnosis of Encounter for other Orthopedic Aftercare and Type 2 Diabetes Mellitus. Physical Therapy was ordered to provide services two times a week for three weeks then one time a week for one week (2WK3, 1WK1). The POC ordered the licensed professional to report vital signs falling outside of the established parameters, including Fasting/Random Blood Sugar result less than 70 or greater than 180 (FBS 180, RBS 180). Review of Patient 9’s Visit Note Report, dated 03/27/23, completed on admission by Staff G, Physical Therapist (PT), showed the patient’s actual blood sugar testing range over the past two weeks was from 165 to 230. The Visit Note Report care coordination, used to document all details of care coordination related to the patient visit, including names and credentials of who care was coordinated with showed: “None of the above.” There was no documentation to support Staff G, PT reported findings to the physician of the patient’s blood sugar testing out of the acceptable parameters ordered on the Plan of Care for a Fasting/Random Blood Sugar result less than 70 or greater than 180 (FBS 180, RBS 180) on admission. Patient 10 Review of Patient 10’s Home Health Certification and Plan of Care (POC) for the Certification Period of 03/27/23 to 05/25/23 showed a primary diagnosis of Unspecified Atrial Fibrillation (abnormal heart rhythm). The POC showed skilled nursing services, physical therapy, occupational therapy and speech therapy were to provide services to the patient. Review of Patient 10’s Visit Note Report, dated 03/29/23, completed by Staff H, Physical Therapy Assistant (PTA), showed the patient reported pain on buttocks from pressure and Staff H recommended a pressure relief cushion with coccyx (tailbone) cutout and memory foam and gel combo. Staff H noted patient had redness and a blood blister just below the coccyx, but reported pain was on each side of the buttocks. Staff H documented the patient may need a cushion for ischial tuberosities (curved bone that makes up the bottom of your pelvis), but the wife and Staff H decided to try the coccyx cutout first and the wife ordered the cushion during the visit. The same document showed the patient started to have sharp stabbing pain about 5 days ago in the lower quadrant of the abdomen and pain on “rear end from pressure lying in bed.” There was no documentation to support Staff H, PTA reported findings to the Physical Therapy Supervisor or the physician regarding the findings on new onset pain in the coccyx and abdominal pain for 5 days, nor the redness and blood blister noted just below the coccyx. Review of Patient 10’s Visit Note Report, dated 04/03/23, completed by Staff C, Occupational Therapy Assistant (COTA), showed the patient reported pain on buttocks and a link was sent to the wife for a ROHO like cushion (an inflatable pressure relief cushion) to decrease discomfort. There was no documentation to support Staff C, COTA reported findings to the Occupational Therapy Supervisor or the physician regarding the patient reported pain in the buttocks and need for another pressure relief cushion. Review of Patient 10’s Visit Note Report, dated 04/03/23, completed by Staff H, Physical Therapy Assistant (PTA), showed the patient reported pain to buttocks over ischial tuberosities and coccyx that was ongoing and started in rehab center without relief; that a pressure relief cushion had been ordered, not received. There was no documentation to support Staff H, PTA reported findings to the Physical Therapy Supervisor or the physician regarding the patient’s reported ongoing pain in the buttocks without relief and lack of pressure relief cushion. Review of the Visit Note Report, dated 04/10/23, completed by Staff C, Certified Occupational Therapy Assistant (COTA), showed the patient reported having difficulty with bowel movements, reported that he had taken “Milk of Mag” (constipation medication) and was awaiting results. The patient reported that his bottom continued to be sore, and the pressure relief cushion should arrive that week. There was no documentation to support Staff C, COTA reported findings to the Occupational Therapy Supervisor or the physician about difficulty with bowel movements requiring medication nor the continued soreness on the patient’s bottom. During an interview on 04/25/20 at 4:40 PM, Staff A, Branch Manager, confirmed therapy assistants report findings to their supervisors and document on the visit note report for care coordination. She confirmed professional staff are primarily responsible for coordinating care with the physician.