Every finding on record at Dynamic Home Health Care, LLC

This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey conducted in your agency from 06/15/2026 through 06/17/2026 in accordance with the applicable Conditions of Participation under 42 CFR 484.102 - Emergency Preparedness Program. The unannounced, on-site inspection was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Health Authority, Bureau of Health Care Quality and Compliance. The findings and conclusions of any investigation by, or on behalf of, the Nevada Health Authority shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. There were no regulatory deficiencies identified.

This Statement of Deficiencies was generated as a result of a Medicare Recertification Survey conducted in your agency from 06/15/2026 through 06/17/2026 in accordance with the applicable Conditions of Participation under 42 CFR 484 – Home Health Agencies. The unannounced, on-site inspection was conducted by Healthcare Management Solutions, LLC on behalf of the Nevada Health Authority, Bureau of Health Care Quality and Compliance. The active census on the first day of the survey was 190. There were 12 active records reviewed and five closed records reviewed. One complaint was investigated: Complaint 114555 deficient practice was identified (see tag G514) The investigation into the allegations included: Observations of staff interactions with seven patients during home visits. Interviews with seven patients, Registered Nurses, Licensed Vocational Nurse, and the Clinical Manager. Review of 17 clinical records, including for the patient of concern, agency policies and procedures, employee files, and the agency’s grievance log. The findings and conclusions of any investigation by, or on behalf of, the Nevada Health Authority shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review, interview, and policy review, the agency failed to transmit Outcome and Assessment Information Set (OASIS) records to the internet Quality Improvement and Evaluation System (iQIES) timely for 5 of 15 quarters (2022, Q4; 2023, Q1; 2023, Q2; 2024, Q4, and 2025, Q4) since their last recertification survey in June 2022. The deficient practice resulted in non-compliance with federal regulations requiring agencies to transmit each OASIS record within 30 days after completion. Findings include: ;0) For Quality Assurance Purposes Only

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interviews, medical record review, document review, and policy review, the agency failed to complete an initial assessment within 48 hours of the referral order date for 1 of 17 sampled patients (Patient 3). Delaying the assessment risked patient safety by failing to identify urgent care and support needs on time. Findings include: .) For quality assurance purposes only

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, interviews, and policy review, the agency failed to ensure that 1 of 6 staff members followed established infection prevention standards and agency policies related to cleaning reusable supplies during a home visit. This deficient practice had the potential to expose all 190 patients currently on the agency's service to an increased risk of infection. Findings include: ;0) For Quality Assurance Purposes Only

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Nevada Department of Health and Human Services. An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 06/27/22 to 06/30/22 resulted in the following findings respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to ensure it maintain a comprehensive emergency preparedness program that meets all the requirements of this section. This deficient practice had the potential to affect the current 238 patients, the current HHA staff, and any future patient admitted for services and any future staff employed or contracted to provide services. Findings include: 1. The HHA failed to ensure its EP plan included a process for the HHA to cooperate with the local, regional, State, and Federal emergency preparedness officials in order to maintain an integrated response during a disaster. (See findings in E0009) 2. The HHA failed to ensure its EP plan included the procedure for the agency to inform State and local emergency preparedness officials about any HHA patients needing evacuation from their residences. (See findings in E0019) 3. The HHA failed to ensure its EP plan included its plan for informing State and local officials of any on-duty staff or patients that the agency was unable to contact. (See findings in tag E0021) 4. The HHA failed to ensure its EP plan included policies and procedures for addressing surge needs during an emergency. (See findings in tag E0024) 5. The HHA failed to ensure its EP communication plan included contact information for Federal, State, and regional emergency preparedness staff. (See findings in tag E0031) 6. The HHA failed to ensure its EP communication plan included alternate means of communication if the telephone lines became unavailable. (See findings in tag E0032) 7. The HHA failed to ensure its EP communication plan included a method the agency would use to share patient information and medical documentation with other health providers to assure continuity of care. (See findings in tag E0033) 8. The HHA failed to ensure its EP communication plan included the method the agency would use to provide information about the agency's occupancy, the agency's needs, and the agency's ability to assist the authority having jurisdiction during a disaster. (See findings in tag E0034) 9. The HHA failed to ensure its EP plan included the training and testing program that was based on its policies and procedures, its risk assessment, and its communication plan and that it would be reviewed and updated at least every two years. (See findings in tag E0036) 10. The HHA failed to provide documentation that agency staff had received EP training at least every two years. (See findings in tag E0037)

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to ensure its EP plan included a process for the HHA to cooperate with the local, regional, State, and Federal emergency preparedness officials in order to maintain an integrated response during a disaster. This deficient practice had the potential to affect the current 238 patients, the current HHA staff, and any future patient admitted for services and any future staff employed or contracted to provide services. Findings include: Review of the HHA's "Emergency Preparedness Packet," reviewed in October and November 2021, indicated there was no process developed for the agency to cooperate with the local, regional, State, and Federal emergency preparedness officials in order to maintain an integrated response during a disaster. The plan included no contact information for the regional, State, and Federal emergency preparedness officials. In an interview on 06/30/22 at 9:15 AM, Clinical Supervisor (CS) confirmed the agency's EP plan did not include contact information for the regional, State, and Federal emergency preparedness officials and a process for cooperating with them during a disaster.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(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. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to ensure its EP plan included the procedure for the agency to inform State and local emergency preparedness officials about any HHA patients needing evacuation from their residences. This deficient practice had the potential to affect the current 238 patients, the current HHA staff, and any future patient admitted for services. Findings include: Review of the HHA's "Emergency Preparedness Packet," dated as reviewed in October and November 2021, indicated there was no procedure developed for the agency to inform State and local emergency preparedness officials about any HHA patients needing evacuation from their residences. The plan included no contact information for the State emergency preparedness officials. In an interview on 06/30/22 at 9:15 AM, Clinical Supervisor (CS) confirmed the agency's EP plan did not include contact information for the State emergency preparedness officials and a procedure for informing State and local EP officials about any agency patients needing evacuation from their homes.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA 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. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to ensure its EP plan included its plan for informing State and local officials of any on-duty staff or patients that the agency was unable to contact. This deficient practice had the potential to affect the current 238 patients, the current HHA staff, and any future patient admitted for services and any future staff employed or contracted to provide services. Findings include: Review of the HHA's "Emergency Preparedness Packet," reviewed in October and November 2021, indicated there was no plan developed that addressed how the agency would inform State and local officials of any on-duty staff or patients that they are unable to contact. The plan included no contact information for the State emergency preparedness officials. In an interview on 06/30/22 at 9:15 AM, Clinical Supervisor (CS) confirmed the agency's EP plan did not include a plan for informing State and local officials of any on-duty staff or patients that they are unable to contact and contact information for State EP officials.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to ensure its EP plan included policies and procedures for addressing surge needs during an emergency. This deficient practice had the potential to affect the current 238 patients, the current HHA staff, and any future patient admitted for services and any future staff employed or contracted to provide services. Findings include: Review of the HHA's "Emergency Preparedness Packet," reviewed in October and November 2021, indicated there was no policy and procedure that addressed surge needs that could be experienced by the agency during an emergency. In an interview on 06/30/22 at 9:15 AM, Clinical Supervisor (CS) confirmed the agency's EP plan did not policies and procedures for addressing surge needs during an emergency.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to ensure its EP communication plan included contact information for Federal, State, and regional emergency preparedness staff. This deficient practice had the potential to affect the current 238 patients, the current HHA staff, and any future patient admitted for services and any future staff employed or contracted to provide services. Findings include: Review of the HHA's "Emergency Preparedness Packet," dated as reviewed in October and November 2021, indicated the communication plan did not include contact information for Federal, State, and regional emergency preparedness staff. In an interview on 06/30/22 at 9:15 AM, Clinical Supervisor (CS) confirmed the agency's EP communication plan did not include contact information for Federal, State, and regional emergency preparedness staff.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to ensure its EP communication plan included alternate means of communication if the telephone lines became unavailable. This deficient practice had the potential to affect the current 238 patients, the current HHA staff, and any future patient admitted for services and any future staff employed or contracted to provide services. Findings include: Review of the HHA's "Emergency Preparedness Packet," dated as reviewed in October and November 2021, indicated the communication plan did not include alternate means of communication in the event the telephone lines were unavailable. In an interview on 06/30/22 at 9:15 AM, Clinical Supervisor (CS) confirmed the agency's EP communication plan did not include how communication would be handled if the telephone lines were unavailable.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to ensure its EP communication plan included a method the agency would use to share patient information and medical documentation with other health providers to assure continuity of care. This deficient practice had the potential to affect the current 238 patients, the current HHA staff, and any future patient admitted for services and any future staff employed or contracted to provide services. Findings include: Review of the HHA's "Emergency Preparedness Packet," dated as reviewed in October and November 2021, indicated the communication plan did not include the method the agency would use to share patient information and medical documentation with other health providers to assure continuity of care. In an interview on 06/30/22 at 9:15 AM, Clinical Supervisor (CS) confirmed the agency's EP communication plan did not include how patient information and medical documentation would be shared with health care providers during a disaster to assure continuity of care.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: Based on emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to ensure its EP communication plan included the method the agency would use to provide information about the agency's occupancy, the agency's needs, and the agency's ability to assist the authority having jurisdiction during a disaster. This deficient practice had the potential to affect the current 238 patients, the current HHA staff, and any future patient admitted for services and any future staff employed or contracted to provide services. Findings include: Review of the HHA's "Emergency Preparedness Packet," dated as reviewed in October and November 2021, indicated the communication plan did not include the method the agency would use to provide information about the agency's occupancy, the agency's needs, and the agency's ability to assist the authority having jurisdiction during a disaster. In an interview on 06/30/22 at 9:15 AM, Clinical Supervisor (CS) confirmed the agency's EP communication plan did not include how the agency would provide information to the authority having jurisdiction during a disaster of the agency's occupancy, the agency's needs, and the agency's ability to assist the authority during the disaster.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to ensure its EP plan included the training and testing program that was based on its policies and procedures, its risk assessment, and its communication plan and that it would be reviewed and updated at least every two years. This deficient practice had the potential to affect the current 238 patients, the current HHA staff, and any future patient admitted for services and any future staff employed or contracted to provide services. Findings include: Review of the HHA's "Emergency Preparedness Packet," dated as reviewed in October and November 2021, indicated the agency's EP plan did not address the training and testing program. In an interview on 06/30/22 at 9:15 AM, Clinical Supervisor (CS) confirmed the agency's EP plan did not address the training and testing program.

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 emergency preparedness (EP) plan review and interview, the home health agency (HHA) failed to provide documentation that agency staff had received EP training at least every two years. This deficient practice had the potential to affect the current 238 patients, the current HHA staff, and any future patient admitted for services and any future staff employed or contracted to provide services. Findings include: Review of the HHA's "Emergency Preparedness Packet," reviewed in October and November 2021, indicated the agency's EP plan did not address the training and testing program. In an interview on 06/30/22 at 9:19 AM, Clinical Supervisor (CS) confirmed the agency's EP plan did not address the training and testing program. CS stated he/she had conducted EP training by Zoom but had not kept documentation of which staff received the training and the date each of the training was provided. CS stated he/she didn't remember if all staff had attended the last Zoom training which was done 08/20/21.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Nevada Department of Health and Human Services. An unannounced on-site Recertification Survey conducted at the above-named Home Health Agency (HHA) from 06/27/22 to 06/30/22 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on policy review, record review, and interviews, the home health agency (HHA) failed to ensure staff performed the initial comprehensive assessment within 48 hours of the referral or discharge from the hospital for five (Patient (P) 2, P3, P4, P9, P11) of 17 patient records reviewed. This deficient practice had the potential to affect the current 238 patients and any future patient admitted to the HHA for home health services. Findings include: Review of the undated policy titled ""Patient Referral Policy" indicated "It shall be the policy of this Agency to have an established referral intake procedure, to insure [sic] patients referred to service are contacted within twenty-four hours and evaluated for admission within forty eight [sic] (48) hours of referral, 48 hours from discharge from hospital or as ordered by the physician or as authorized by the patients [sic] insurance company. . ." All patient records were paper copies presented by Owner and had no chart dividers separating each section of the record. 1. Review of P2's medical record indicated an order was received on 05/16/22 to admit P2 to "Home health care PT" [physical therapy]. Further review indicated P2 was discharged from the hospital on 05/16/22. Review of P2's "Comprehensive Adult Assessment" documented by Registered Nurse (RN) 1 indicated the assessment was performed on 05/19/22, more than 48 hours after the referral was received and P2 was discharged from the hospital. In an interview on 06/30/22 at 11:15 AM, Administrator stated P2 was discharged from the hospital on 05/16/22, but P2's managed care organization didn't authorize the admission until 05/17/22. Administrator confirmed there was no order received from P2's physician to delay the admission to 05/19/22. 2. Review of P3's medical record indicated an order was received on 05/24/22 for PT home health care. Review of P3's medical record indicated P3's start of care (SOC) was 05/27/22, more than 48 hours after the referral was received and P3 was discharged from the hospital. There was no physician order approving the delay in the SOC. In an interview on 06/30/22 at 11:15 AM, Administrator confirmed there was no physician order in P3's medical record approving a delay in P3's SOC. 3. Review of P4's medical record indicated an order was received on 06/07/22 to admit to home health for skilled nursing to perform dressing changes daily. Review of P4's medical record indicated P4's SOC was 06/17/22, 10 days after receipt of the order for home health care. Review of P4's "Physician Orders" dated 06/08/22 and documented by RN3 indicated "Delay SOC per patients [sic] request as patient saw wound care experts on 6/7, and patient had appt [appointment] conflict the beginning of week of 6/13." There was no documentation of who received the order, the date and time the order was received, who the order was received from, and a verbal order read back verification. In an interview on 06/30/22 at 11:30 AM, Administrator stated they eventually get a doctor's signature on the "Physician Order" form, so the section for verbal order isn't being completed. Administrator confirmed the section related to verbal order on the "Physician Orders" form for P4 was not completed by the nurse. Administrator confirmed there was no order for the delay in the SOC that was read back and verified. 4. Review of P9's medical record indicated an order was received on 03/18/22 for physical therapy home health care. Review of P9's "Physician Orders" dated 03/22/22 and documented by RN3 indicated "Delay SOC until 3/25/2022 per patients [sic] request. . ." There was no documentation of who received the order, the date and time the order was received, who the order was received from, and a verbal order read back verification. In an interview on 06/30/22 at 11:30 AM, Administrator stated they eventually get a doctor's signature on the "Physician Order" form, so the section for verbal order isn't being completed. Administrator confirmed the section related to verbal order on the "Physician Orders" form for P4 was not completed by the nurse. Administrator confirmed there was no order for the delay in the SOC that was read back and verified. 5. Review of P11's medical record indicated an order was received on 02/10/22 for "Home Services Referral." Review of P11's "Physician Orders" dated 02/19/22 and documented by RN3 indicated "Delay SOC [start of care] until 2/19 per patients request as patient had multiple appointments and wanted to wait until Saturday for the nurse to come." There was no documentation of who received the order, the date and time the order was received, who the order was received from, and a verbal order read back verification. In an interview on 06/30/22 at 11:30 AM, Administrator stated they eventually get a doctor's signature on the "Physician Order" form, so the section for verbal order isn't being completed. Administrator confirmed the section related to verbal order on the "Physician Orders" form for P11 was not completed by the nurse. Administrator confirmed there was no order for the delay in the SOC that was read back and verified.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, medical record reviews, and interviews, the home health agency (HHA) failed to ensure the agency staff documented physician verbal orders in accordance with agency policy for five (Patient (P) 2, P3, P4, P5, P15) of five patient records reviewed for verbal orders from a sample of 17 patient records. This deficient practice had the potential to affect the current 238 patients and any future patient admitted to the HHA for home health services. Findings include: Review of the "Verbal Orders Policy," effective 11/26/19, indicated ". . . Orders will be obtained from a licensed physician (or allowed practitioner) for care and services to be provided to home health patients. Verbal orders will be spoken to, taken and documented only by professional, licensed home health personnel. . . 1. All verbal or telephone orders . . . will be "read back" and confirmed by the physician (or allowed practitioner) or designee to ensure accuracy of the order or test result. 2. Verbal orders will be documented on a Care Coordination form . . . Order will then be written on Physicians Order Form and sent out for physician . . . signature. . ." All patient records were paper copies presented by Owner and had no chart dividers separating each section of the record. 1. Review of P2's "Physician Orders," dated 06/17/22 and documented by Physical Therapist (PT) 3, indicated the order included the PT frequency of three times a week for four weeks starting 06/20/22 and the PT treatment plan. Further review indicated the order did not indicate whether the order was a "verbal order" or a "non-verbal order." There was no documentation of the name of the staff who received the order, the date the order was received, who the order was received from, the time the order was received, the effective date of the order, and that the verbal order was read back and verified (lines provided for this information to be entered). Further review indicated PT visits were made prior to the physician order signed 06/21/22 being received. In an interview on 06/30/22 at 11:30 AM, Administrator stated they get a doctor's signature on the "Physician Order" form, so the section for verbal order isn't being completed. Administrator stated in the communication note, the staff documents that they discuss the frequency with the physician and then write an order. Administrator confirmed the section related to verbal order on the "Physician Orders" form for P2 was not completed by the nurse according to the agency policy. 2. Review of P3's "Physician Orders" dated 06/18/22 and documented by Registered Nurse (RN) 2 indicated an order to resume care with visit frequency for the nurse of one time a week for one week starting 06/18/22, two times a week for two weeks starting 06/20/22, and one time a week for one week starting 07/04/22. Further review indicated the order did not indicate whether the order was a "verbal order" or a "non-verbal order." There was no documentation of the name of the staff who received the order, the date the order was received, who the order was received from, the time the order was received, the effective date of the order, and that the verbal order was read back and verified (lines provided for this information to be entered). In an interview on 06/30/22 at 11:30 AM, Administrator stated they get a doctor's signature on the "Physician Order" form, so the section for verbal order isn't being completed. Administrator stated in the communication note, the staff documents that they discuss the frequency with the physician and then write an order. Administrator confirmed the section related to verbal order on the "Physician Orders" form for P3 was not completed by the nurse according to the agency policy. 3. Review of P4's "Physician Orders," dated 06/08/22 and documented by RN3, indicated an order to delay the start of care per P4's request. Further review indicated the order did not indicate whether the order was a "verbal order" or a "non-verbal order." There was no documentation of the name of the staff who received the order, the date the order was received, who the order was received from, the time the order was received, the effective date of the order, and that the verbal order was read back and verified (lines provided for this information to be entered). In an interview on 06/30/22 at 11:30 AM, Administrator stated they get a doctor's signature on the "Physician Order" form, so the section for verbal order isn't being completed. Administrator stated in the communication note, the staff documents that they discuss the frequency with the physician and then write an order. Administrator confirmed the section related to verbal order on the "Physician Orders" form for P4 was not completed by the nurse according to the agency policy. 4.Review of P5's medical record indicated physician/admission orders documented on 06/13/22 by RN3, on 06/22/22 by Occupational Therapist (OT) 1, and on 06/22/22 by PT4 did not include documentation of the name of the staff who received the order, the date the order was received, who the order was received from, the time the order was received, the effective date of the order, and that the verbal order was read back and verified (lines provided for this information to be entered). In an interview on 06/30/22 at 11:30 AM, Administrator stated they get a doctor's signature on the "Physician Order" form, so the section for verbal order isn't being completed. Administrator stated in the communication note, the staff documents that they discuss the frequency with the physician and then write an order. Administrator confirmed the section related to verbal order on the "Physician Orders" form for P5 was not completed by OT1, RN3, and PT4 according to the agency policy. 5. Review of P15's "Physician Orders," dated 04/29/22 and documented by PT2, indicated an order was received PT two times a week for two weeks starting 05/02/22 and included the PT treatment plan. Further review indicated the order did not indicate whether the order was a "verbal order" or a "non-verbal order." There was no documentation of the name of the staff who received the order, the date the order was received, who the order was received from, the time the order was received, the effective date of the order, and that the verbal order was read back and verified (lines provided for this information to be entered). In an interview on 06/30/22 at 11:30 AM, Administrator stated they get a doctor's signature on the "Physician Order" form, so the section for verbal order isn't being completed. Administrator stated in the communication note, the staff documents that they discuss the frequency with the physician and then write an order. Administrator confirmed the section related to verbal order on the "Physician Orders" form for P15 was not completed by PT2 according to the agency policy.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on policy review, medical record reviews, and interviews, the home health agency (HHA) failed to ensure a physician's order had been received for services provided for three (Patient (P) 3, P12, P15) of 17 patient records reviewed. This deficient practice had the potential to affect the current 238 patients and any future patient admitted to the HHA for home health services. Findings include: Review of the agency policy titled, "Plan of Care Policy," revised 05/24/10, indicated ". . . It shall be the policy of this Agency to implement an individualized Plan of care established by the patient's physician for each patient. . . A licensed nurse will ensure initial orders for an evaluation / initial skilled services are received from a patient's physician, prior to rendering care. A physician's verbal order for the evaluation visit is documented on the Intake Form and on a physician's order by the nurse receiving the order. . . The Plan of Care will include . . . j. Medications/treatments/procedures including who is to administer the medication and/or who is to perform the treatment or procedure, a description of the procedure/treatment to be done. . .Significant modifications in acre are documented on a Physician's order form and mailed to the physician for signature and date. . ." Review of the agency policy titled, "Verbal Orders Policy," effective 11/26/19, indicated ". . . Orders will be obtained from a licensed physician (or allowed practitioner) for care and services to be provided to home health patients. Verbal orders will be spoken to, taken and documented only by professional, licensed home health personnel. . . 1. All verbal or telephone orders . . . will be "read back" and confirmed by the physician (or allowed practitioner) or designee to ensure accuracy of the order or test result. 2. Verbal orders will be documented on a Care Coordination form . . . Order will then be written on Physicians Order Form and sent out for physician . . . signature. . ." All patient records were paper copies presented by Owner and had no chart dividers separating each section of the record. 1. Review of P3's "Physician Orders" dated 06/18/22 and documented by Registered Nurse (RN) 2 indicated an order to resume care with visit frequency for the nurse of one time a week for one week starting 06/18/22, two times a week for two weeks starting 06/20/22, and one time a week for one week starting 07/04/22. Further review indicated the order did not indicate whether the order was a "verbal order" or a "non-verbal order." There was no documentation of the name of the staff who received the order, the date the order was received, who the order was received from, the time the order was received, the effective date of the order, and that the verbal order was read back and verified (lines provided for this information to be entered). Review of P3's medical record indicated a skilled nurse visit was completed on 06/18/22 without having a verbal order to perform the visit. In an interview on 06/30/22 at 11:30 AM, Administrator stated they get a doctor's signature on the "Physician Order" form, so the section for verbal order isn't being completed. Administrator stated in the communication note, the staff documents that they discuss the frequency with the physician and then write an order. Administrator confirmed the section related to verbal order on the "Physician Orders" form for P3 was not completed by the nurse according to the agency policy. 2. Review of P12's "Admission Orders," dated 05/13/22 and documented by RN1, indicated orders for skilled nursing, skilled nursing frequency of one week for one week starting 05/13/22 and two weeks for four weeks starting 05/23/22, and physician therapy (PT) to evaluate. Further review indicated there was no documentation of the name of the staff who received the order, the date the order was received, who the order was received from, the time the order was received, the effective date of the order, and that the verbal order was read back and verified (lines provided for this information to be entered). Further review indicated nursing visits were conducted prior to the signed physician order being received. Review of P12's "Admission Orders," dated 05/16/22 and documented by Physical Therapist (PT) 1, indicated an order for PT two times a week for four weeks starting 05/16/22, the PT treatment plan, and the PT short term and long-term goals. Further review indicated PT visits were conducted prior to the signed physician order being received. In an interview on 06/30/22 at 11:30 AM, Administrator stated they get a doctor's signature on the "Physician Order" form, so the section for verbal order isn't being completed. Administrator stated in the communication note, the staff documents that they discuss the frequency with the physician and then write an order. Administrator confirmed the section related to verbal order on the "Physician Orders" form for P12 was not completed by RN1 and PT1 according to the agency policy. 3. Review of P15's "Physician Orders," dated 04/29/22 and documented by PT2, indicated an order was received PT two times a week for two weeks starting 05/02/22 and included the PT treatment plan. Further review indicated the order did not indicate whether the order was a "verbal order" or a "non-verbal order." There was no documentation of the name of the staff who received the order, the date the order was received, who the order was received from, the time the order was received, the effective date of the order, and that the verbal order was read back and verified (lines provided for this information to be entered). Review of P15's medical record indicated PT visits were conducted the week of 05/02/22 prior to the agency receiving the signed physician order for the visits (a verbal order was not documented for the visits). In an interview on 06/30/22 at 11:30 AM, Administrator stated they get a doctor's signature on the "Physician Order" form, so the section for verbal order isn't being completed. Administrator stated in the communication note, the staff documents that they discuss the frequency with the physician and then write an order. Administrator confirmed the section related to verbal order on the "Physician Orders" form for P15 was not completed by PT2 according to the agency policy.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on policy review, record reviews, observations, and interviews, the home health agency (HHA) failed to ensure each patient's medication profile was kept current with the medications in the home that the patient was taking as observed during home visits on 06/28/22 and 06/29/22 for five (Patient (P) 1, P3, P4, P5, P7) of five home visits conducted from a sample of 17 patients. This deficient practice had the potential to affect the current 238 patients and any future patient admitted to the HHA for home health services. Findings include: Review of the agency policy titled, "Medication Profile/Reconciliation," revised 11/26/12, indicated ". . . The registered Nurse or Therapist will complete a medication profile for each patient at the time of admission. The medication profile shall include all prescription and nonprescription drugs, including regularly scheduled medications and those taken intermittently or as needed. The profile will be reviewed and updated as needed to reflect current medications the patient is taking. . . If the physician changes the medication orders, the Nurse must add newly ordered drugs or medication changes to the Medication Profile. Discontinued medications shall be highlighted and documented as "DC" with the appropriate date. . ." All patient records were paper copies presented by Owner and had no chart dividers separating each section of the record. 1. Observation during a home visit on 06/28/22 at 10:30 AM revealed the following changes in P1's medications from what was listed on P1's "Medication Profile" for the certification period of 06/08/22 to 08/06/22 that was reviewed on 06/05/22: a. Tresiba (long-acting basal insulin indicated to improve glycemic control in patients with diabetes) 100 unit/ml (unit per milliliter), take 17 units subcutaneously daily was listed on the medication profile with a start date of 02/19/20. In an interview on 06/28/22 at 10:30 AM, P1 stated he/she currently took 22 units/ml. b. Cyclobenzaprine HCL (used short term to treat muscle spasms) 10 mg (milligram) tablet, take one tablet twice per day was listed on the medication profile with a start date of 02/19/20. In an interview on 06/28/22 at 10:30 AM, P1 stated he/she doesn't take the medication any longer. c. Atorvastatin calcium (used along with a proper diet to help lower "bad" cholesterol and fats (such as LDL, triglycerides) and raise "good" cholesterol) 10 mg tablet, take one orally daily was listed on the medication profile with a start date of 02/19/20. The bottle in the home that was undated and had a note of "one refill until 01/27/23" had instructions to take 20 mg at bedtime. d. Pregabalin (used along with other medications to treat certain types of seizures) 300 mg capsule, take one capsule daily was listed on the medication profile with a start date of 02/11/21. The bottle in the home dated 02/22/22 had instructions to take two times a day. e. Hydroxyzine HCL (used to treat itching caused by allergies) 25 mg tablet, take one every eight hours as needed was listed on the medication profile with a start date of 02/11/21. In an interview on 06/28/22 at 10:30 AM, P1 stated he/she doesn't take the medication any longer. f. Trulicity (once-weekly injectable prescription medicine to improve blood sugar (glucose) in adults with type 2 diabetes) 0.75 mg/0.5 ml subcutaneous every Monday at bedtime was listed on the medication profile with a start date of 10/09/21. The syringe of Trulicity presented by P1 (not in a box with a date on it) had a dose of 1.5 mg/0.5 ml. In an interview on 06/28/22 at 10:30 AM, P1 stated this was the current dose P1 was taking. g. A bottle dated 06/01/22 of Tizanidine (short-acting muscle relaxer) 4 mg with instructions to take one tablet three times a day was in the home and not listed on the medication profile. In an interview on 06/28/22 at 10:30 AM, P1 stated this prescription was given to replace Cyclobenzaprine HCL. h. A bottle Potassium Cl ER (mineral supplement used to treat or prevent low amounts of potassium in the blood) with instructions to take one tablet two times a day dated 02/10/22 was in the home and not listed on the medication profile. In an interview on 06/28/22 at 10:30 AM, P1 confirmed he/she was taking Atorvastatin Calcium, Pregabalin, and Potassium Cl ER as listed above. In an interview on 06/28/22 at 10:30 AM, Licensed Practical Nurse (LPN) 1 stated he/she had not done a review of the medication profile on visits LPN1 made since the profile was completed on 06/05/22. 2. Observation during a home visit on 06/28/22 at 12:55 PM revealed the following changes in P3's medications from what was listed on P3's "Medication Profile" for the certification period of 05/27/22 to 07/25/22 that was reviewed on 05/27/22: a. The following medications were listed on the medication profile, but P3 stated in an interview on 06/28/22 at 12:55 PM that P3 was no longer taking the medications: Augmentin (antibiotic used to treat bacterial infections) 875 mg-125 mg tablets, take one twice a day, ascorbic acid (nutrient the body needs to form blood vessels, cartilage, muscle and collagen in bones and vital to the body's healing process) 500 mg tablet, take one daily, cholecalciferol (dietary supplement that is used to treat vitamin D deficiency) 125 mcg (micrograms) tablet, take one daily, dexamethasone (relieves inflammation and used to treat certain forms of arthritis) 6 mg tablet, take one tablet daily, doxycycline hyclate (used to treat a wide variety of bacterial infections) 100 mg, take one tablet twice a day, Qualifenesin (used to relieve chest congestion) 100 mg/5mg ml, take 5 ml orally as needed, zinc (nutrient found throughout your body that helps the immune system and metabolism function) 50 mg tablet, take one tablet daily; famotidine 20 mg tablet, take one daily, megestrol acetate (used to treat loss of appetite and weight loss) 40 mg tablet, take one tablet twice a day, and metoprolol tartrate (used with or without other medications to treat high blood pressure) 100 mg Tablet, take one tablet twice a day. All above medications were dated with a start date of 05/27/22 on P3's medical profile. b. Furosemide (strong diuretic ('water pill') that may cause dehydration and electrolyte imbalance) 40 mg tablet, take one tablet daily, was listed on the medication profile with a start date of 05/27/22. A bottle in the home dated 05/24/22 had instructions to take one tablet twice a day for 14 days. c. The following medication bottles were in the home and were not listed on P3's medication profile: Gabapentin (treats seizures by decreasing abnormal excitement in the brain) 100 mg, take one orally twice a day, bottle dated 04/13/22, Carvedilol (used to treat heart failure and high blood pressure) 12.5 mg, take one orally twice a day, bottle dated 05/26/22, Eliquis (blood thinner medicine that reduces blood clotting) 2.5 mg, take one twice a day, bottle dated 04/28/22, oxybutynin (used to treat symptoms of an overactive bladder) 5 mg, take one twice a day, bottle dated 02/16/22, levothyroxine (used to treat an underactive thyroid gland) 75 mcg, take one daily, bottle dated 06/21/22, and glipizide ER (extended release used to control high blood sugar in people with type 2 diabetes) 2.5 mg tablet, take one daily, bottle dated 06/20/22. In an interview on 06/28/22 at 12:55 PM, P3 confirmed the above changes to his/her medications. 3. Observation during a home visit on 06/28/22 at 2:30 PM revealed P4's "Medication Profile" for the certification period of 06/17/22 to 08/15/22 that was reviewed on 06/17/22 included Gabapentin (treats seizures by decreasing abnormal excitement in the brain) 600 mg tablet, take one tablet every four to six hours as needed. Observation of the bottle in the home dated 05/24/22 revealed instructions to take one tablet twice a day. In an interview on 06/28/22 at 2:55 PM, P4 stated he/she took Gabapentin according to the instructions on the bottle. 4. Observation during a home visit on 06/29/22 at 12:30 PM revealed P5's "Medication Profile" for the certification period of 06/19/22 to 08/17/22 that was reviewed on 06/17/22 included Carvedilol (used to treat heart failure and high blood pressure) 6.25 mg tablet with instructions to take one tablet twice a day with a start date of 10/22/21. Observation of a bottle dated 05/18/22 revealed Carvedilol 3.125 mg rather than 6.25 mg. Further observation revealed a bottle of hydrocodone/acetaminophen 5-325 (used to relieve moderate to severe pain) with instructions to take one three times a day as needed for pain. Hydrocodone/acetaminophen 5-325 was not listed on P5's "Medication Profile." In an interview on 06/29/22 at 12:30 PM, P5's spouse confirmed P5 was taking Carvedilol 3.125 mg one tablet twice a day and Hydrocodone/Acetaminophen 5-325 as needed for pain. 5. Observation during a home visit on 06/29/22 at 4:15 PM revealed P7's "Medication Profile" for the certification period of 0527/22 to 07/25/22 that was reviewed on 05/27/22 included the following medications that P7's spouse stated P7 was no longer taking (in an interview on 06/29/22 at 4:15 PM): Eliquis (blood thinner medicine that reduces blood clotting) 2.5 mg tablets, take one twice a day, Cholecalciferol (dietary supplement that is used to treat vitamin D deficiency) 50 mcg, take one capsule daily, Feosol (iron supplement used to treat or prevent low blood levels of iron) 325 mg tablet, take one every other day, Robaxin (used to treat the symptoms of muscle spasms caused by pain or injury) 500 mg tablet, take one tablet three times a day as needed, vitamin E (important to vision, reproduction, and the health of the blood, brain and skin) 180 mg capsule, take one every other day, and Jevity (fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) 1.2 cal/237 ml, take three cans daily per gastrostomy tube. Review of medication bottles in the home during the home visit on 06/29/22 at 4:15 PM revealed the following two medications that were present but not included on P7's "Medication Profile": Bottle dated 04/11/22 of anastrozole (hormone therapy) 1 mg with instructions to take one daily and Bottle dated 11/16/21 of omeprazole (used to treat certain conditions where there is too much acid in the stomach) 20 mg with instructions to take one daily. In an interview on 06/29/22 at 4:15 PM, P7's spouse stated P7 was taking anastrozole and omeprazole as listed above.

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 policy review, observations, and interviews, the home health agency (HHA) failed to ensure staff implemented standard precautions, specifically related to hand hygiene and glove use, in accordance with agency policy as observed during five (Patient (P) 1, P3, P4, P5, P7) of five home visits conducted on 06/28/22 and 06/29/22. This deficient practice had the potential to affect the current 238 patients and any future patient admitted to the HHA for home health services. Findings include: Review of the policy titled "Hand Hygiene," revised 04/01/20, indicated ". . . Hand hygiene should be performed at a minimum: a. Before entering nursing bag . . . b. Before contact with a patient . . . f. between tasks and procedures on the same patient g. Before and after touching a wound h. After gloves are removed . . . j. After touching inanimate sources that are potentially contaminated . . . l. When hands are visibly soiled. . ." Review of the agency policy titled, "Cleaning of Reusable Equipment Policy," revised 05/24/10, indicated ". . . 2. All equipment and working surfaces will be cleaned and decontaminated immediately after contact or potentially infectious materials with a 1:10 [one-to-ten] bleach solution or PDI Super Sani cloth or Dispatch towels with bleach. 3. Gloves, and if necessary, protective coverings are to be worn to protect the staff person from contamination when cleaning or decontaminating any equipment. . . 7. Each staff person will be responsible for the cleaning of their reusable equipment. . ." 1. Observation during a home visit on 06/28/22 at 10:45 AM revealed Licensed Practical Nurse (LPN) 1 donned gloves to wrap P1's legs with ace wraps. LPN1 then disinfected the scissors used during patient care while wearing the contaminated gloves worn to wrap P1's legs with ace wraps. LPN assessed P1's blood pressure with bare hands. After contact with P1 and without completing hand hygiene LPN1 then disinfected his/her stethoscope and blood pressure cuff. In an interview on 06/28/22 at 11:25 AM, LPN1 confirmed the above documented patient and equipment care were breaches in the agency's hand hygiene policy. 2. Observation during a home visit on 06/28/22 at 12:55 PM revealed Physical Therapist (PT) 3 assessed P3's blood pressure and oxygen saturation while wearing gloves. After the assessment, PT3 disinfected the blood pressure cuff and pulse oximeter while wearing the contaminated gloves used during patient contact. Observation revealed PT3 did not remove his/her gloves, sanitize his/her hands, and apply new gloves to disinfect the patient care equipment. In an interview on 06/28/22 at 1:30 PM, PT3 confirmed the above actions were breaches in the agency's hand hygiene policy. 3. Observation during a home visit on 06/28/22 at 2:30 PM revealed Registered Nurse (RN) 5 assessed P4's oxygen saturation while wearing gloves. RN5 then placed the pulse oximeter in its storage pouch while wearing contaminated gloves. RN5 did not disinfect the pulse oximeter before storing the pulse oximeter after patient use. Observation on 06/28/22 at 2:38 PM revealed RN5 placed the stethoscope used to assess P4's heart and lung sounds in his/her pants pocket without disinfecting the stethoscope and placing the stethoscope in the nurse's bag. In an interview on 06/28/22 at 3:03 PM, RN5 stated he/she cleans/disinfects patient care equipment before using it at the next patient's home and has "always carried my stethoscope in my pants pocket." RN5 asked the surveyor "where am I supposed to put my stethoscope"? 4. Observation during a home visit on 06/29/22 at 12:50 PM with P5 revealed Occupational Therapist (OT) 1 wiped his/her gloved hands with a "Purel" alcohol wipe after completing patient care. OT1 then had P5 sign the visit note on OT1's personal phone while wearing the same gloves used to perform patient care. OT1 then wiped his/her cell phone with a "Purel" alcohol wipe while wearing the same gloves used to perform patient care and placed the cell phone in OT1's pocket. OT1 then placed his/her blood pressure cuff in OT1's bag while wearing contaminated gloves. In an interview on 06/29/22 at 1:00 PM, OT1 stated OT1 had disinfected the blood pressure after patient use prior to the surveyor's arrival in the home. OT1 stated he/she thought he/she didn't need to remove his/her gloves until OT1 completed the visit. When asked if OT1 had received education on infection control and hand hygiene and glove use by the HHA, OT1 stated "Yes." 5. Observation during a home visit on 06/29/22 at 4:20 PM with P7 revealed OT2 cleaned patient care equipment after use with a Clorox wipe, removed his/her gloves, and donned another pair of gloves without performing hand hygiene. In an interview on 06/29/22 at 4:40 PM, OT2 confirmed he/she did not perform hand hygiene after removing gloves and before donning a new pair of gloves.

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 policy review, document reviews, interview, and the Center for Medicare and Medicaid Services (CMS), the home health agency (HHA) failed to ensure: 1. the agency's COVID-19 vaccination policy contained the required content as identified by CMS, and 2. the agency had documentation of the approval for requested exemptions based on religious beliefs for two of two staff, (Registered Nurse (RN) 4, Physical Therapist (PT) 5), who were documented as being granted exemptions for religious beliefs from a sample of 14 staff COVID-19 vaccination documentations reviewed. This deficient practice had the potential to affect the current 238 patients, all current staff, any future patient admitted to the HHA for home health services, and any future staff employed or contracted to provide home health services. Findings include: 1. Review of "QSO-22-07-All Guidance for the Interim Final rule-Medicare and Medicaid Programs; Omnibus COVID-19 Health Care Staff Vaccination," Revised 04/05/22, indicated the components that must be included at a minimum in the agency policy regarding staff COVID-19 vaccinations. Review of the agency policy titled, "Addendum to Infection Control/Exposure Plan Policy (COVID 19) – COVID 19 Vaccination Requirements," revised 01/13/22, revealed the agency policy did not include the following content required in the federal regulation. a. The process for tracking and securely documenting the COVID-19 vaccination status of all staff. b. 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. c. A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law. d. 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. e. 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 (i) 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 (ii) 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. f. 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. In an interview on 06/30/22 at 10:15 AM, Clinical Supervisor (CS) confirmed the agency's COVID-19 vaccination policy did not include the above-listed processes. 2. The review of the agency policy titled, "Addendum to Infection Control/Exposure Plan Policy (COVID 19) – COVID 19 Vaccination Requirements," revised 01/13/22, also indicated ". . . Healthcare workers may be exempt from the vaccination requirements upon submission of a declination form signed by the individual stated either of the following: a) The worker is declining vaccination based on religious beliefs b) The worker is excused from receiving any COVID 19 vaccine due [sic] qualifying medical reason. . ." Review of RN4's personnel file indicated RN4 requested a religious exemption on 12/01/21. There was no documentation of the request being granted. Review of PT5's personnel file indicated PT5 requested a religious exemption on 12/19/21. There was no documentation of the request being granted. In an interview on 06/30/22 at 10:15 AM, CS confirmed there was no documentation that RN4's and PT5's exemption request from the COVID-19 vaccination based on religious beliefs had been granted. CS stated a process for approval of requests for exemption had not been addressed in the agency's policy.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on policy reviews, record reviews, observation, and interviews, the home health agency (HHA) failed to ensure staff followed physician orders in the patients' plan of care (POC) for 10 (Patient (P) 1, P2, P3, P4, P6, P8, P9, P10, P12, P13) of 17 records reviewed. Specifically, the HHA failed to ensure (1) wound care orders were accurate for the wound care being performed and (2) the agency followed its policy regarding POC orders for missed visits. The deficient practices had the potential to affect the current 238 patients and any future patient admitted to the HHA for home health services. Findings include: Review of the policy titled "Missed Visit Policy," revised 05/24/10, indicated ". . . It shall be the policy of this Agency that a missed visit note will be written every time scheduled visit is not completed. The discipline who missed the visit will notify the office that such visit was not completed. . . The Missed visit note will act as a visit in the frequency sequence of the plan of care. . . The physician will be notified of such missed visit and it will be documented on the completed note that the physician was in fact notified. . ." Review of the policy titled "Plan of Care Policy," revised 05/24/10, indicated ". . . It shall be the policy of this Agency to implement an individualized Plan of care established by the patient's physician for each patient. . . A licensed nurse will ensure initial orders for an evaluation / initial skilled services are received from a patient's physician, prior to rendering care. A physician's verbal order for the evaluation visit is documented on the Intake Form and on a physician's order by the nurse receiving the order. . . The Plan of Care will include . . . j. Medications/treatments/procedures including who is to administer the medication and/or who is to perform the treatment or procedure, a description of the procedure/treatment to be done. . . Changes in the patient that warrant changes in the Plan of Care include but are not limited to the following: . . . Missed visits that change the frequency of visits. If a visit is missed and does not change the frequency, a note must be written explaining the circumstances of the missed visit and the physician must be notified. If a missed visit changes the frequency, the physician must be notified, and an order must be obtained to change the frequency. 8. Significant modifications in care are documented on a Physician's order form and mailed to the physician for signature and date. . ." All patient records were paper copies presented by Owner and had no chart dividers separating each section of the record. 1. Review of P4's "Plan of Care" for the certification period of 06/17/22 to 08/15/22 indicated an order for wound care to P4's right side of the neck that read "Cleanse with NS [normal saline], pat dry, pack with Aquacel Ag [silver] Advanced ribbon, cover with bordered foam daily." Review of P4's "Skilled Nurse Visit Note" documented by Registered Nurse (RN) 5 on 06/18/22, 06/19/22, 06/20/22, 06/21/22, 06/22/22, 06/23/22, and 06/24/22 indicated RN5 documented that he/she packed P4's right neck wound with Aquacel Ag Advanced ribbon as ordered. Observation during a home visit on 06/28/22 at 2:38 PM revealed RN5 opened a sterile pack of Aquacel Ag and cut strips to be used to pack P4's neck wound. There was no observation of Aquacel Ag Advanced ribbon used as packing. Review of P4's medical record indicated there was no documentation that RN5 notified P4's physician that Aquacel Ag Advanced ribbon was not available for wound care and no physician order to replace the ribbon with strips cut from sterile pack of Aquacel Ag. In a telephone interview on 06/29/22 at 11:00 AM, RN5 stated he/she used a pack of sterile Aquacel Silver that had to be cut into strips and was not in ribbon form as ordered. RN5 confirmed he/she opens a new sterile pack of Aquacel Silver each visit. RN5 confirmed he/she documented the wound care as having used the Aquacel Silver Advanced ribbon. RN stated "the doctor is using what I'm using and said to cut it into a ribbon" when asked by the surveyor if RN5 received an order for the different wound care supply. RN5 confirmed he/she did not document a physician's order for the actual wound care that was being performed and was not documenting the actual care that was being performed. 2. a. Review of P1's "Plan of Care" for the certification period of 04/09/22 to 06/07/22 indicated the nurse frequency was three times a week for nine weeks starting 04/07/22. Review of P1's "Skilled Nurse Visit Note" indicated a nursing visit was made on 04/07/22 and 04/09/22. There was no documentation that a third nursing visit was made the week of 04/07/22 (start of care) to 04/10/22 (end of the first week of the certification period). There was no documentation that a missed visit note was documented and that P1's physician was notified of the missed visit. Review of P1's "Skilled Nurse Visit Note" indicated two nursing visits were made on 05/30/22 and 06/02/22. There was no documentation of a third nursing visit the week of 05/30/22. There was no documentation of a physician's order to change the nursing frequency for the weeks of 04/07/22, 04/10/22, and 05/30/22. b. Review of P2's "Plan of Care" for the certification period of 05/19/22 to 07/17/22 indicated the nursing frequency was two times a week for one week starting 05/23/22 then one time a week for one week starting 05/30/22. Review of P2's medical record a nursing visit was missed on 05/28/22 that changed P2's POC. There was no documentation of a physician's order to change P2's frequency as a result of the missed visit. c. Review of P3's "Plan of Care" for the certification period of 05/27/22 to 07/25/22 indicated the nursing frequency was two times a week for two weeks starting 05/30/22, one time a week for one week starting 06/13/22, and one time a week starting 05/27/22. Review of P3's medical record indicated a nursing visit was missed on 06/01/22 and 06/24/22 that changed P3's POC. There was no documentation of a physician's order to change P3's frequency as a result of the missed visits. d. Review of P6's "Plan of Care" for the certification period of 05/11/22 to 07/09/22 indicated the nursing frequency was three times a week for nine weeks starting 05/10/22. Review of P6's medical record indicated a nursing visit was missed the week of 05/16/22, 05/30/22, 06/13/22, and 06/20/22 that resulted in a change in P6's POC. There was no documentation of a physician's order to change P6's frequency as a result of the missed visits. d. Review of P8's "Plan of Care" for the certification period of 04/23/22 to 06/21/22 indicated a resumption of care order with the physical therapy (PT) frequency of two times a week for two weeks starting 06/06/22 then one time a week for one week starting 06/20/22. Review of P8's medical record indicated a physical therapy visit was missed on 06/09/22 and 06/14/22 that changed P8's POC. There was no documentation of a physician's order to change P8's frequency as a result of the missed visits. e. Review of P9's "Plan of Care" for the certification period of 03/25/22 to 05/23/22 indicated the PT frequency was two times a week for four weeks starting 03/29/22. Review of P9's medical record indicated a physical therapy visit was missed 04/07/22, 04/12/22, 04/26/22, and 04/27/22 that resulted in a change to P9's POC. There was no documentation of a physician's order to change P9's frequency as a result of the missed visits. f. Review of P10's "Plan of Care" for the certification period of 06/13/22 to 08/11/22 indicated the nursing frequency was two times a week for two weeks, and the aide frequency was two times a week for five weeks. Review of P10's medical record indicated a nursing visit was missed on 06/25/22, and an aide visit was missed on 06/14/22. These missed visits resulted in a change in the nursing and aide frequency in P10's POC. There was no documentation of a physician's order to change P10's frequency as a result of the missed visits. g. Review of P12's "Plan of Care" for the certification period of 05/13/22 to 07/11/22 indicated the nursing frequency was one time a week for one week starting 05/13/22 then two times a week for four weeks starting 05/16/22. Review of P12's medical record indicated a nursing visit was missed on 05/24/22 and 05/31/22 that resulted in a change in P12's POC. There was no documentation of a physician's order to change P12's frequency as a result of the missed visits. h. Review of P13's "Plan of Care" for the certification period of 01/18/22 to 03/18/22 indicated the nursing frequency was four times a week for one week starting 01/18/22 then six times a week for eight weeks starting 01/24/22. Review of P13's medical record indicated nursing visits were missed on 03/03/22, 03/06/22, 03/13/22, and 03/17/22 that resulted in a change in P13's POC. There was no documentation of a physician's order to change P13's frequency as a result of the missed visits. In an interview on 06/30/22 at 11:15 AM, Administrator stated the missed visit notification policy indicated the physician needs to be notified of the missed visit, but it does not require a change in frequency order. Administrator stated he/she was not aware the plan of care policy stated that an order was needed with a missed visit when the frequency changed. Administrator stated there are no physician orders for any patients whose frequency changed due to missed visits, because Administrator was not aware of the discrepancy in the wording in the missed visit policy and the plan of care policy.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on policy review, record reviews, and interviews, the home health agency (HHA) failed to ensure agency staff communicated with the physician when patient visits were missed for nine (Patient (P) 1, P2, P3, P6, P8, P9, P10, P12, P13) of 17 patient records reviewed. This deficient practice had the potential to affect the current 238 patients and any future patient admitted to the HHA for home health services. Findings include: Review of the policy titled "Missed Visit Policy," revised 05/24/10, indicated ". . . It shall be the policy of this Agency that a missed visit note will be written every time scheduled visit is not completed. The discipline who missed the visit will notify the office that such visit was not completed. . . The physician will be notified of such missed visit and it will be documented on the completed note that the physician was in fact notified. . ." All patient records were paper copies presented by Owner and had no chart dividers separating each section of the record. 1. Review of P1's "Plan of Care" for the certification period of 04/09/22 to 06/07/22 indicated the nurse frequency was three times a week for nine weeks starting 04/07/22. Review of P1's "Skilled Nurse Visit Note" indicated a nursing visit was made on 04/07/22 and 04/09/22. There was no documentation that a third nursing visit was made the week of 04/07/22 (start of care) to 04/10/22 (end of the first week of the certification period). There was no documentation that a missed visit note was documented and that P1's physician was notified of the missed visit. Review of P1's "Skilled Nurse Visit Note" indicated two nursing visits were made on 05/30/22 and 06/02/22. There was no documentation of a third nursing visit the week of 05/30/22. In an interview on 06/30/22 at 11:15 AM, Administrator confirmed P1's medical record had no documentation that P1's physician was notified of the missed visits during the weeks of 04/07/22 and 05/30/22. 2. Review of P2's "Plan of Care" for the certification period of 05/19/22 to 07/17/22 indicated the nursing frequency was two times a week for one week starting 05/23/22 then one time a week for one week starting 05/30/22. Review of P2's "Skilled Nurse Patient Missed Visit" note dated 05/28/22 documented by Registered Nurse (RN) 1 indicated the "Notification" section had "Physician notified of missed visit" checked with no completion of the choices of "Via telephone: time of call spoke with" or "Via Facsimile with confirmation (attach confirmation print out to this form) Number faxed to time and date." In an interview on 06/30/22 at 11:15 AM, Administrator stated the missed visit report is faxed to the physician, but he/she has no documentation to present that shows the number the fax was sent to and the time and date of the fax. Administrator confirmed the notification section of the missed visit note is not completed, and there was no confirmation print out attached to the form in accordance with agency policy. 3. Review of P3's "Plan of Care" for the certification period of 05/27/22 to 07/25/22 indicated the nursing frequency was two times a week for two weeks starting 05/30/22, one time a week for one week starting 06/13/22, and one time a week starting 05/27/22. Review of P3's "Skilled Nurse Patient Missed Visit" note dated 06/01/22 and 06/24/22 documented by Licensed practical Nurse (LPN) 1 indicated the "Notification" section on each note had "Physician notified of missed visit" checked with no completion of the choices of "Via telephone: time of call spoke with" or "Via Facsimile with confirmation (attach confirmation print out to this form) Number faxed to time and date." In an interview on 06/30/22 at 11:15 AM, Administrator stated the missed visit report is faxed to the physician, but he/she has no documentation to present that shows the number the fax was sent to and the time and date of the fax. Administrator confirmed the notification section of the missed visit note is not completed, and there was no confirmation print out attached to the form in accordance with agency policy. 4. Review of P6's "Plan of Care" for the certification period of 05/11/22 to 07/09/22 indicated the nursing frequency was three times a week for nine weeks starting 05/10/22. Review of P6's "Skilled Nurse Visit Note" indicated three nursing visits were not conducted the weeks of 05/16/22 (two visits made), 05/30/22 (two visits made), 06/13/22 (two visits made), and 06/20/22 (two visits made). There was no documentation that P6's physician was notified of the missed visits, and there was no documentation of a missed visit note. In an interview on 06/30/22 at 11:15 AM, Administrator confirmed there was no documentation of a missed visit note on the above weeks and no documentation that P6's physician was notified of the missed visits. 5. Review of P8's "Plan of Care" for the certification period of 04/23/22 to 06/21/22 indicated a resumption of care order with the physical therapy (PT) frequency of two times a week for two weeks starting 06/06/22 then one time a week for one week starting 06/20/22. Review of P8's medical record indicated a "Physical Therapy Patient Missed Visit" note was documented on 06/09/22 and 06/14/22 by Physical Therapy Assistant) 1. Review of each note indicated the "Notification" section on each note had no check mark for "Physician notified of missed visit." In an interview on 06/30/22 at 11:15 AM, Administrator confirmed the missed visit notes had no documentation that P8's physician was notified of the missed visits. 6. Review of P9's "Plan of Care" for the certification period of 03/25/22 to 05/23/22 indicated the PT frequency was two times a week for four weeks starting 03/29/22. Review of P9's medical record indicated a "Physical Therapy Patient Missed Visit" note was documented by Physical Therapist (PT) 6 for missed visits on 04/07/22, 04/12/22, 04/26/22, and 04/27/22 with the reason of "PT out of office." Review of each note indicated the "Notification" section on each note had no check mark for "Physician notified of missed visit." In an interview on 06/30/22 at 11:15 AM, Administrator stated the PT visit should have been scheduled with another PT when PT6 was out of the office. Administrator stated sometimes the patient refuses another PT, but if this occurred, that should have been documented. Administrator confirmed the PT missed visit note did not have documentation that P9's physician was notified of the missed PT visits. 7. Review of P10's "Plan of Care" for the certification period of 06/13/22 to 08/11/22 indicated the nursing frequency was two times a week for two weeks, and the aide frequency was two times a week for five weeks. Review of P10's "Skilled Nurse Patient Missed Visit" documented on 06/25/22 by RN7 indicated the "Notification" section on the note had no check mark for "Physician notified of missed visit." Review of P10's "CHHA [home health aide] Patient Missed Visit" note documented on 06/14/22 by RN3 indicated the "Notification" section on the note had no check mark for "Physician notified of missed visit." In an interview on 06/30/22 at 11:15 AM, Administrator confirmed the missed visit notes had no documentation that P10's physician was notified of the missed visits. 8. Review of P12's "Plan of Care" for the certification period of 05/13/22 to 07/11/22 indicated the nursing frequency was one time a week for one week starting 05/13/22 then two times a week for four weeks starting 05/16/22. Review of P12's medical record indicated "Skilled Nurse Patient Missed Visit" notes dated 05/24/22 and 05/31/22 documented by RN1. Further review of each note indicated the "Notification" section on each note had no check mark for "Physician notified of missed visit." In an interview on 06/30/22 at 11:15 AM, Administrator confirmed the missed visit note had no documentation that P12's physician was notified of the missed visits. 9. Review of P13's "Plan of Care" for the certification period of 01/18/22 to 03/18/22 indicated the nursing frequency was four times a week for one week starting 01/18/22 then six times a week for eight weeks starting 01/24/22. Review of P13's medical record indicated "Skilled Nurse Patient Missed Visit" notes dated 03/03/22, 03/06/22, 03/13/22, and 03/17/22 documented by LPN1. Review of each note indicated the "Notification" section on each note had no check mark for "Physician notified of missed visit." In an interview on 06/30/22 at 11:15 AM, Administrator confirmed the missed visit note had no documentation that P13's physician was notified of the missed visits.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on policy review, observations, and interviews, the home health agency (HHA) failed to monitor, manage, and maintain the equipment used to access the web-based system. This deficient practice had the potential to affect the current 238 patients and any future patient admitted to the HHA for home health services. Findings include: Review of the policy titled "Confidentiality of Patient Information Policy," revised 05/24/10, indicated ". . . It shall be the policy of this Agency to maintain strict confidentiality of all information pertaining to patient care. . . Staff members are to take steps to prevent the unauthorized disclosure of a patient's clinical record when using copies of the record in the field. . . Staff members are to insure [sic] patient information is kept out of sight of others when not in use. . . All clinical records are to be filed in a secured area when not being supervised by Agency personnel, or when the Agency is closed. . . Any staff use of their own personal phone or tablet for patient visit documentation will be treated in the same manner to maintain the confidentiality of patient information." Review of the policy indicated there was no documentation of the method the agency would use to ensure staff's personal phones and tablets used for documentation would maintain confidentiality of patient information. 1. Observation during a home visit on 06/29/22 at 12:50 PM revealed Occupational Therapist (OT) 1 documented Patient (P) 5's visit on OT1's personal phone. In an interview on 06/29/22 at 12:50 PM, OT1 confirmed he/she uses his/her personal phone to document patient visits. 2. Observation during a home visit on 06/29/22 at 4:00 PM revealed OT2 documented P7's visit on his/her personal tablet. In an interview on 06/29/22 at 4:00 PM, OT2 confirmed he/she used his/her personal tablet to document patient visits. In an interview on 06/30/22 at 11:15 AM, when informed that staff were observed during home visits on 06/29/22 using personal cell phones and tablets for documentation, Administrator asked the surveyor if the surveyor was aware that all documentation goes through a web-based system. Administrator offered no explanation regarding how staff's personal cell phones and tablets were monitored, managed, and maintained to assure patient confidentiality was maintained.