Every finding on record at Divine Home Health Care LLC

EMERGENCY PREPAREDNESS SURVEY The following deficiency is based on the emergency preparedness survey completed on 10/12/22.

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 document review and staff interview, the agency failed to provide training and to maintain documentation of training on the emergency preparedness plan upon hire and at least every two years for all staff for 12 of 95 employees (Staff G, H, I, J, K, L, M, N, O, P, Q, and R). This could affect all patients receiving services from the agency. The agency census was 121 patients. Findings include: Review of the emergency preparedness binder and emergency preparedness education revealed 12 employees (Staff G, H, I, J, K, L, M, N, O, P, Q, and R) lacked documentation of emergency preparedness education in the last two years. On 10/12/22 at 4:00 PM, Staff M stated that he/she was unaware the emergency preparedness education was required upon hire. Staff M stated the agency provided annual emergency preparedness education so those hired since the last training would not have completed it yet. Staff M verified that the documentation for these 12 staff members could not be located at this time.

Partial Extended Recertification Survey An entrance conference was conducted on 10/04/22 at 10:15 AM with administrative personnel, and an exit conference was completed on 10/12/22 at 4:20 PM with administrative personnel. The following deficiencies are based on the Partial Extended Recertification survey completed on 10/12/22. Divine Home Health Care LLC 368298, is not in compliance with the requirements found at 42 CFR Part 484 Subpart B, C for Home Health Agencies.

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 observation, medical record review, policy review, and staff interview, the agency failed to review 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 for one of three home visits conducted (Patient #1). The total patient sample was seven. This could affect all patients receiving services from the agency. The agency census was 121. Findings include: During the home visit with Patient #1 on 10/04/22 at 12:22 PM, Staff C was observed to fill the patient's medication box for one week. Staff C was observed to place Carvedilol (for high blood pressure) 6.25 milligrams (mg) one tablet, Spironolactone (for high blood pressure and water retention) 25 mg half of a tablet, and Gabepentin (medication for nerve pain) 100 mg one capsule just once per day in the medication box. Staff C stated Patient #1 only took these medications once a day. Review of the medical record for Patient #1 revealed a plan of care and the medication profile listed Carvedilol 6.25 mg two tablets twice a day, Spironolactone 25 mg half of a tablet twice a day, and Gabapentin 100 mg one capsule three times a day. The medical record lacked documentation of physician notification or new orders regarding these medications. Review of the undated policy titled, "Medication Reconciliation," revealed on admission the admitting clinician would document a complete list of medications that the patient was taking and the registered nurse would reconcile any discrepancies with the patient's physician. The medication profile would be updated with each new or changed medication. The findings were verified in an interview with Staff A on 10/11/22 at 3:05 PM. Staff A stated Staff C had discussed the medication changes with the physician but had not updated the medication profile, written a new order changing the medication dosages, or documented the communication with the physician.

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 medical record review and staff interview, the agency failed to ensure patients received the home health services as written in the plan of care for six of seven medical records reviewed (Patient #1, #3, #4, #5, #6, and #7). This could affect all patients receiving services from the agency. The agency census was 121. Findings include: 1. Review of the medical record for Patient #1 revealed a plan of care dated 08/11/22 to 10/09/22 with orders for home health aide services 13 hours per week. The medical record contained documentation of home health aide services provided as follows: six hours of home health aide services were provided the week of 08/11/22 to 08/13/22; 14.5 hours of home health aide services were provided the week starting 08/14/22; 14 hours of home health aide services the week starting 08/28/22; 12 hours of home health aide services the week starting 09/11/22; 13 hours and 41 minutes of home health aide services the week starting 10/02/22. The medical record lacked documentation of additional orders or physician notification that services were not provided as ordered. The findings were verified in an interview with Staff A on 10/11/22 at 3:05 PM. 2. Review of the medical record for Patient #3 revealed plans of care dated 06/23/22 to 08/21/22 and 08/22/22 to 10/20/22 with orders for skilled nursing twice a week and home health aide services 40 to 49 hours per week. The plans of care lacked documentation of orders for telehealth services. Review of the medical record revealed documentation of two telehealth nursing visits the week starting 08/07/22 but lacked documentation of any in-person nursing visits this week. Review of the home health aide notes from 07/31/22 through 10/01/22 revealed home health aide services were provided from 49 hours and 37 minutes to 52 hours and 40 minutes per week. The medical record lacked documentation of additional orders or physician notification that services were not provided as ordered. The findings were verified in an interview with Staff A on 10/11/22 at 3:05 PM. 3. Review of the medical record for Patient #4 revealed an order dated 08/10/22 to amend the plan of care dated 08/10/22 to 10/08/22 with orders for skilled nursing three times a week. Review of the medical record revealed documentation of one in-person nursing visit and two telehealth nursing visits the week starting 08/07/22. The medical record lacked documentation of any orders for telehealth services. The medical record lacked documentation of additional orders or physician notification that services were not provided as ordered. The findings were verified in an interview with Staff A on 10/11/22 at 3:05 PM. 4. Review of the medical record for Patient #5 revealed plans of care dated 07/05/22 to 09/02/22 with orders for skilled nursing weekly. The plans of care lacked documentation of orders for telehealth services. Review of the medical record revealed documentation of one telehealth nursing visit the week starting 08/07/22 but lacked documentation of any in-person nursing visits this week. The medical record lacked documentation of additional orders or physician notification that services were not provided as ordered. The findings were verified in an interview with Staff A on 10/11/22 at 3:05 PM. 5. Review of the medical record for Patient #6 revealed plans of care dated 01/22/22 to 03/22/22 and 03/23/22 to 05/21/22 with orders for skilled nursing visits weekly. The medical record lacked documentation of nursing visits the weeks starting 03/27/22, 04/03/22, 04/24/22, 05/01/22, 05/08/22, and 05/15/22. The medical record lacked documentation of additional orders or physician notification that services were not provided as ordered. The findings were verified in an interview with Staff A on 10/11/22 at 3:05 PM. 6. Review of the medical record for Patient #7 revealed a plan of care dated 04/12/22 to 06/10/22 with orders for physical therapy (PT), occupational therapy (OT), and speech therapy (ST) evaluations. The medical record contained an OT evaluation and orders dated 04/18/22 for OT twice a week for seven weeks. The medical record contained a PT evaluation and orders dated 04/19/22 for PT three times a week for eight weeks. The medical record contained a ST evaluation and orders dated 04/20/22 for ST twice a week for seven weeks. The medical record lacked documentation of any OT, PT, or ST visits after the evaluation visits. The medical record lacked documentation of additional orders or physician notification that services were not provided as ordered. The findings were verified in an interview with Staff B on 10/12/22 at 12:05 PM.

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 medical record review, policy review, and staff interview, the agency failed to ensure the plans of care included advance directives and risk and interventions to prevent emergency department/hospital readmission for seven of seven medical records reviewed (Patient #1, #2, #3, #4, #5, #6, and #7). This could affect all patients receiving services from the agency. The agency census was 121. Findings include: 1. Review of the medical record for Patient #1 revealed a plan of care dated 08/11/22 to 10/09/22. The plan of care lacked documentation of the risk and interventions to prevent emergency department/hospital readmission. 2. Review of the medical record for Patient #2 revealed plans of care dated 07/10/22 to 09/07/22 and 09/08/22 to 11/06/22. The plans of care lacked documentation of advance directives and the risk and interventions to prevent emergency department/hospital readmission. 3. Review of the medical record for Patient #3 revealed plans of care dated 06/23/22 to 08/21/22 and 08/22/22 to 10/20/22. The plans of care lacked documentation of the risk and interventions to prevent emergency department/hospital readmission. 4. Review of the medical record for Patient #4 revealed plans of care dated 06/11/22 to 08/09/22 and 08/10/22 to 10/08/22. The plans of care lacked documentation of the risk and interventions to prevent emergency department/hospital readmission. 5. Review of the medical record for Patient #5 revealed plans of care dated 07/05/22 to 09/02/22 and 09/03/22 to 11/01/22. The plans of care lacked documentation of the risk and interventions to prevent emergency department/hospital readmission. 6. Review of the medical record for Patient #6 revealed plans of care dated 01/22/22 to 03/22/22 and 03/23/22 to 05/21/22. The plans of care lacked documentation of the risk and interventions to prevent emergency department/hospital readmission. 7. Review of the medical record for Patient #7 revealed a plan of care dated 04/12/22 to 06/10/22. The plan of care lacked documentation of the risk and interventions to prevent emergency department/hospital readmission. The findings were verified in an interview with Staff A on 10/11/22 at 3:05 PM.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, review of guidance from the Centers for Disease Control and Prevention and staff interview, the agency failed to ensure accepted standards of practice were used to prevent the transmission of COVID 19 during two of three home visits (Patient #1 and Patient #3). This had the potential to affect all patients receiving services from the agency. The census was 121 patients. Findings include: Review of the Centers for Disease Control Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 09/23/22 revealed healthcare personnel should wear a N95 respirator or a well-fitting facemask during patient encounters. Healthcare settings refers to places where healthcare is delivered and includes but is not limited to home healthcare. 1. On 10/04/22 at 12:22 PM during the home visit with Patient #1, Staff C was observed without a face mask. 2. On 10/05/22 at 10:08 AM during the home visit with Patient #2, Staff S was observed without a face mask. The findings were verified in an interview with Staff A on 10/11/22 at 3:05 PM. Staff A stated staff were expected to wear a face mask in patient homes.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on review of QSO memo 22-09-ALL Revised Attachment G, policy review, staff vaccination record review, and staff interview, the home health agency failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated for Covid-19, except for those who have been granted exemptions for five of 95 staff (Staff D, E, F, G, and H). The agency's vaccination rate was 92.6 percent. This could affect all patients receiving services from the agency. The census was 121. Findings include: Review of QSO memo 22-09-ALL Revised Attachment G, revised 04/05/22, revealed that within 60 days following the issuance of the applicable memorandum home health agencies must develop and implement policies and procedures for ensuring all facility staff, regardless of clinical responsibility or resident contact are fully vaccinated for COVID-19, including all required components of the policies and procedures and 100% of staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple vaccine series) or have been granted a qualifying exemption, or are identified as having a temporary delay as recommended by the Centers for Disease Control (CDC). The policies and procedures must include a process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, have been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by and in accordance with all applicable state and local laws, and for further ensuring that such documentation contains the following: all information specifying which of the COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications and a statement by the authenticating practitioner recommending that the staff member be exempted from the agency's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications. Review of the undated policy titled, "COVID-19 Vaccination Extention Policy," revealed medical exemptions must provide a signed and dated statement from a licensed practitioner recommending the medical exemption from the agency requirement to be fully vaccinated based on the recognized clinical contraindications. The policy contained a Centers for Disease Control website address to obtain the clinical considerations for use of the Covid-19 vaccines currently authorized or approved in the United States. Review of the undated agency policy titled, "COVID-19 Vaccination Policy," revealed official documentation of vaccination status must be provided to the Human Resources Department and include the following information: the type of vaccine administered, the date(s) of administration, the name of the healthcare professional or clinic site administering the vaccine. A vaccination card from a healthcare provider or pharmacy, a completed CDC-issued vaccine card, or medical records is sufficient to verify vaccination status. Review of the agency's Covid-19 vaccination records revealed a 92.6 percent fully vaccinated or have an approved exemption rate. 1. Review of Staff D's medical exemption documentation revealed a physician prescription which stated "per patient preference" but lacked documentation of any medical diagnosis or contraindications to vaccination but was signed and dated by the physician. 2. Review of the vaccination information for Staff E revealed he/she had received the first dose of a two dose vaccination series on 02/22/21 but lacked documentation of the second dose. 3. Review of the vaccination information for Staff F revealed he/she had received the first dose of a two dose vaccination series on 04/30/21 but lacked documentation of the second dose. 4. Review of the vaccination information for Staff G revealed he/she had received one dose of a two dose vaccination series on 12/21/21. This was documented on the "Other" line on the Covid-19 Vaccination Card but lacked documentation of the first two doses of the series. 5. Review of the vaccination information for Staff H revealed he/she had received one dose of a two dose vaccination series on 06/08/22. This was documented on the "Other" line on the Covid-19 Vaccination Card but lacked documentation of the first two doses of the series. The vaccination documentation lacked documentation of a good faith effort to obtain the missing documentation. The findings were verified in an interview with Staff A on 10/12/22 at 4:15 PM.