Every finding on record at Eh Health Home Health of the Northwest LLC

Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) §484.102 Emergency Preparedness (EP) Condition of Participation for Home Health Agencies effective 04/16/21, an EP survey was performed on 08/28/25. The facility reviewed their EP plan on 8/30/23. Deficiencies were cited.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to maintain an emergency preparedness plan that was based on the facility-based and community-based risk assessment and included strategies for addressing emergency events identified by the risk assessment. Findings include: Review of the agency's Hazard Risk Assessment tool, dated 6/25/25, reflected snowfall, blizzards, ice storms, temperature extremes, and wildfires as the areas of high probability risk. Review of the agency's emergency preparedness plan, dated 8/30/23, reflected the agency's EP plan did not include plans for snowfall, blizzards, ice storms, temperature extremes, or wildfires. During an interview on 8/27/25 at 2:00 p.m., staff members A and B stated the agency's emergency plan did not reflect the specific areas of snowfall, blizzards, or wildfires. Staff member B stated the plan was developed at the corporate level and was not specific to the agency's risk assessment.

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), §485.542(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, REHs at §485.542, "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 record review and interview, the agency failed to ensure initial training in emergency preparedness policies and procedures was completed by all new and existing staff. Findings include: Review of emergency preparedness training files via Teams with staff members B and H on 8/27/25 at 3:30 p.m., reflected emergency preparedness training was not completed for staff members I, J, and K. During an interview on 8/27/25 at 3:45 p.m., staff member H stated the agency records showed staff members I, J, and K had not completed the online courses for EP that were assigned to them.

A recertification survey was completed by the State of Montana, Office of Inspector General, Certification Bureau, on 8/28/25. Standard and Condition level deficiencies were cited. Abbreviations: COVID: Coronavirus Disease IQIES: Internet Quality Improvement and Evaluation System LPN - Licensed Practical Nurse LTC - Long Term Care OASIS - Outcome and Assessment Information Set OT - Occupational Therapy PT - Physical Therapy QAPI: Quality Assurance and Performance Improvement RN - Registered Nurse ROC - Resumption of Care SOC - Start of Care

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 observation, interview, and record review, the agency failed to accurately reflect the living situation at the time of an Admission OASIS for 1 (#6) of 20 sampled patients. Findings include: During a home visit observation on 8/27/25 at 12:19 p.m., patient #6 was residing in his home with his spouse. Review of patient #6's Admission OASIS, dated 8/15/25, showed: -(M1100) The description of the patient's residential circumstance and availability of assistance was documented as the patient lived alone. The Admission OASIS failed to accurately reflect patient #6 lived with his spouse in their home. During an interview on 8/28/25 at 12:35 p.m., staff member C stated herself and staff member B audited OASIS documentation for discrepancies before submission. Staff member C stated the Admission OASIS for patient #6 was missed for accuracy.

Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on interview and record review, the agency was found to not be in substantial compliance with the Conditions of Participation for Patient Rights. -The agency failed to ensure patients were free from mental abuse (G0430); -The agency failed to investigate a complaint made by a patient's family member regarding inappropriate care and accusations of mental abuse by a staff member (G0478); -The agency failed to produce documentation for each complaint received that showed the actions taken by the agency to remove any risks to the patient while the complaint was being investigated; failed to document an investigation was conducted; failed to record the findings; and failed to document the resolution of the complaint (G0486); and -The agency failed to report allegations of verbal abuse by a family member and mistreatment by a staff member to the appropriate state agency in accordance with state law (G0488).

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patients were free from mental abuse for 1 (#20) of 20 sampled patients. Findings include: Review of a complaint report, dated 6/23/25, reflected a family member called the agency to complain about the care provided by the nurse for patient #20. The complaint reflected the nurse had threatened to discontinue care and became angry if patient #20 and family disagreed with her on the treatment plan, not allowing for discussion of patient #20's preferences. The follow-up on the complaint reflected a different nurse was assigned to patient #20's care and the original staff member was re-educated. No investigation was noted, and no documentation reflected the staff member was removed from patient care pending investigation of the allegation of abuse. During an interview on 8/27/25 at 2:10 p.m., staff member B stated the agency did not have any additional documentation to support the investigation. Review of the agency's policy, Patient abuse, neglect, and exploitation [State], dated 9/25/24, reflected: "... 2.1 Abuse means: 2.1.1 The infliction of physician or mental injury..."

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) The HHA must— (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: (A) Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately; (B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to investigate complaints made by a patient's family member for 3 (#s18, 19, and 20) of 20 sampled patients. Findings include: Review of an agency complaint record, dated 8/27/24, reflected patient #18 had concerns with the staffing schedule for his care. Review of the complaint record for patient #18 showed there was no documentation of an investigation being completed, the record lacked information showing any actions taken by the agency to remove any risks to the patient, and the document lacked the findings and resolution of the complaint. Review of an agency complaint record, dated 8/29/24, reflected patient #19 had concerns with the staffing times and dates for his care. Review of the complaint record for patient #19 showed there was no documentation of an investigation being completed, the record lacked information showing any actions taken by the agency to remove any risks to the patient, and the document lacked the findings and resolution of the complaint. Review of a complaint report, dated 6/23/25, reflected a family member called the agency to complain about the care provided by the nurse for patient #20. The complaint reflected the nurse had threatened to discontinue care and became angry if patient #20 and family disagreed with her on the treatment plan, not allowing for discussion of patient #20's preferences. The follow-up on the complaint reflected a different nurse was assigned to patient #20's care and the original staff member was re-educated. No further investigation was noted, and no documentation reflected the staff member was removed from patient care pending investigation was found. The follow-up note reflected the following: "... It seems the issue is a conflict between this nurse and communication and expectations." During an interview on 3/26/25 at 2:10 p.m., staff member B stated the complaints for patient #s 18 and 19 were submitted during the time a different branch manager was responsible for completing the investigations. Staff member B stated the branch manager no longer worked for the agency and she could not speak as to why the complaints were not investigated. Staff member B stated there was no documentation to show staff or other patients were interviewed regarding the concerns made by patient #20's family. Review of the agency's policy, Patient complaints and grievances, dated 10/24/24, reflected: "... 1.1 Facilitate the investigation and resolution of a patient's complaint. 1.2 Confirm that the patient receives appropriate care, without discrimination or reprisal, during and following the investigation of the complaint. ..."

Protect patient during investigation CFR(s): 484.50(e)(1)(iii) (iii) Take action to prevent further potential violations, including retaliation, while the complaint is being investigated. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to produce documentation for each complaint received that showed the actions taken by the agency to remove any risks to the patient while the complaint was being investigated; failed to document an investigation was conducted; failed to record the findings; and failed to document the resolution of the complaint for 1 (# 20) of 20 sampled patients. Findings include: Review of a complaint report, dated 6/23/25, reflected a family member called the agency to complain about the care provided by the nurse for patient #20. The complaint reflected the nurse had threatened to discontinue care and became angry if patient #20 and family disagreed with her on the treatment plan, not allowing for discussion of patient #20's preferences. The follow-up on the complaint reflected a different nurse was assigned to patient #20's care and the original staff member was re-educated. No further investigation was noted, and no documentation reflected the staff member was removed from patient care pending investigation was found. The follow-up note reflected the following: "... It seems the issue is a conflict between this nurse and communication and expectations." During an interview on 8/27/25 at 2:10 p.m., staff member B stated the agency did not have any additional documentation the agency removed the staff member from any patient care during the investigation, investigated the staff member's care of patients through interviews of staff or patients. Staff member B stated it was the expectation the staff member be removed from patient care, a thorough root cause investigation be completed and documented, along with a corrective action plan. Staff member B stated all areas should be documented and would be kept on file. Staff member B stated she did not know why the investigations were incomplete or why the staff member was not removed from patient care. Review of the agency's policy, Patient abuse, neglect, and exploitation [State], dated 9/25/24, reflected: "... 2.1 Abuse means: 2.1.1 The infliction of physician or mental injury..."

Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to report allegations of verbal abuse by a family member and mistreatment by a staff member to the appropriate state agency in accordance with state law for 2 (#s15 and 20) of 20 sampled patients. Findings include: 1. Review of patient #15's client coordination note, dated 2/20/25, reflected patient #15 stated she needed to get away from her son and needed to move out. The nurse's observations reflected, "…son seems angry and agitated. Says bad things about [State] and all [State residents]. He is mildly intimidating." Review of patient #15's client coordination note, dated 3/7/25, reflected patient #15 stated, "... I need to get out of here. He's going to kill me." The note reflected patient #15 and her son were fighting, the son was raising his voice, telling the patient to "shut the [explicative] up," the son was taking all the patient's money to drink beer, and the son was telling the patient to get out of the home. The nurse documented in the note she contacted a family member who, "...confirmed they go at each other every day. And he is mean to her." 2. Review of a complaint report, dated 6/23/25, reflected a family member called the agency to complain about the care provided by the nurse for patient #20. The complaint reflected the nurse had threatened to discontinue care and became angry if patient #20 and family disagreed with her on the treatment plan, not allowing for discussion of patient #20's preferences. Review of the state agency IQIES system, as of 8/27/25, did not reflect a state report had been filed since 5/21/13. No reports were found for patient #15 or #20. During an interview on 8/27/25 at 2:10 p.m., staff member B stated the agency did not file state agency reports. Staff member B stated she did not have access to the state reporting system for filing state agency reports. Review of the agency's policy, Patient abuse, neglect, and exploitation [State], dated 9/25/24, reflected: "... 4.3.3.1 Immediately submits verbal report of the suspected patient abuse, neglect, and/or exploitation to appropriate authority in accordance with relevant statutes."

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the agency was found to not be in substantial compliance with the Condition of Participation for Comprehensive Assessment of Patients. Findings include: -The agency failed to perform an initial assessment visit within 48 hours of the referral date to provide immediate care and support to patients (G0514).

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 interview and record review, the agency failed to perform an initial assessment visit within 48 hours of the referral date to provide immediate care and support for 9 (#s 3, 8, 9, 10, 12, 13, 14, 16, and 17) of 20 sampled patients. Findings include: Review of patient #3's [Hospital's name] Order Requisition for Home Health Referral, dated 7/25/25 at 11:16 a.m., showed the requested start of care date of 7/25/25. The document showed initial skilled services of physical therapy and occupational therapy. Review of patient #3's Admission OASIS and initial assessment visit, dated 7/31/25, showed: -(M0090) The date the assessment was completed was 7/31/25. -(M1005) The patient was discharged from inpatient care on 7/25/25. The agency failed to perform patient #3's initial assessment within the required 48 hours of the referral date. *****Toshua interview with Amber about initial assessment within 48 hours. 1.Review of patient #8's Home Health Referral form, dated 7/15/25, reflected orders for Physical therapy and Occupational therapy. Review of resident #8's Visit Note Report, dated 7/18/25, reflected resident #8 was admitted to services on 7/18/25, three days after the referral orders were received. 2. Review of patient #9's Home Health Referral, dated 6/9/25, reflected orders for Home Health Services. Review of resident #9's Visit Note Report, dated 6/12/25, reflected resident #9 was admitted to services on 6/12/25, three days after the referral orders were received. 3. Review of patient #10's Home Health Referral, dated 5/15/25, reflected orders for Home Health Services. Review of resident #10's Visit Note Report, dated 5/21/25, reflected resident #10 was admitted to services on 5/21/25, six days after the referral orders were received. 4. Review of patient #12's Home Health Referral, dated 8/13/25, reflected orders for Home Health Services. Review of resident #12's Visit Note Report, dated 8/19/25, reflected resident #12 was admitted to services on 8/19/25, six days after the referral orders were received. 5. Review of patient #13's Home Health Referral, dated 12/27/23, reflected orders for Home Health Services. Review of resident #13's Visit Note Report, dated 1/3/24, reflected resident #13 was admitted to services on 1/3/24, seven days after the referral orders were received. 6. Review of patient #14's Home Health Referral, dated 2/7/25, reflected orders for Home Health Services. Review of resident #14's Visit Note Report, dated 2/10/25, reflected resident #14 was admitted to services on 2/10/25, three days after the referral orders were received. 7. Review of patient #16's Home Health Referral order, dated 5/16/24, reflected orders for Physical therapy and Occupational therapy. Review of resident #16's Visit Note Report, dated 5/20/24, reflected resident #16 was admitted to services on 5/20/24, four days after the referral orders were received. 8. Review of patient #17's Home Health Referral, dated 12/27/24, reflected orders for Home Health Services. Review of patient #17's Critical care admission to [Hospital Name], dated 1/5/25, reflected patient #17 was admitted to the hospital for COVID-pneumonia, gap metabolic acidosis, and a very abnormal urinalysis consistent with a urinary tract infection, nine days after the referral was received. Review of patient #17's Home Health Referral, dated 1/9/25, reflected orders for Home Health Services. Review of resident #17's Visit Note Report, dated 1/13/25, reflected resident #17 was admitted to services on 1/13/25, four days after the second set of referral orders were received. During an interview on 8/27/25 at 1:25 p.m., staff member B stated the cause of the delays for initial assessments was staffing. Staff member B stated weekend and holiday admissions were difficult for staffing and the agency did not typically admit patients on weekends or nights. Staff member B stated the expectation was the initial assessments, and comprehensive assessments were done together within 48 hours, regardless of the discipline completing the admission. Review of the agency's policy 1.10 Authorization and Intake, revised 8/26/25, reflected: -"... 9. SOC/ROC Timely initiation of Care (TIC)occurs when the initial assessment visit is conducted within 48 hours of the complete referral date or inpatient discharge date whichever is later, or on the specific physician ordered date if one was provided."

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the agency was found to not be in substantial compliance with the Condition of Participation for Infection Prevention and Control. Findings include: -The agency failed to adhere to standard precautions, to prevent the transmission of infections and communicable diseases, in the patient's environment (G0682); -The agency failed to ensure an agency-wide infection control program was maintained for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases (G0684); and -The agency failed to ensure infection control training was completed on hire for staff members (G0686).

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, interview, and record review, the agency failed to ensure staff member D adhered to standard precautions, to prevent the transmission of infections and communicable diseases, in the patient's environment for 5 (#s 1, 2, 4, 5, and 6) of 6 sampled home visit patients. Findings include: 1. During an observation on 8/26/25 at 9:53 a.m., staff member D placed her clinical bag onto patient #1's kitchen chair, which had a soft neck cushion on the chair seat. Staff member D had not placed a clean barrier on the chair, under the clinical bag. 2. During an observation on 8/26/25 at 12:45 p.m., staff member D retrieved her clinical bag out of the back of the agency's car to enter patient #4's home. During an observation on 8/26/25 at 12:58 p.m., staff member D placed her clinical bag onto patient #4's kitchen countertop. Staff member D had not placed a clean barrier on the countertop, under the clinical bag. 3. During an observation on 8/27/25 at 8:58 a.m., staff member D placed her clinical bag onto a magazine, which was lying on patient #5's coffee table. Staff member D had not placed a clean barrier on the table, under the clinical bag. 4. During an observation on 8/27/25 at 12:18 p.m., staff member D retrieved her clinical bag out of the back of the agency's car to enter patient #6's home. During an observation on 8/27/25 at 12:24 p.m., staff member D placed her clinical bag onto patient #6's coffee table. Staff member D had not placed a clean barrier on the table. During an interview on 8/27/25 at 1:07 p.m., staff member D stated if she saw dirt or dust on a surface, she considered it dirty, otherwise she considered it clean. Staff member D stated she did not clean the surface of her bag in-between home visits, which was retrieved from the back of the agency's car. 5. During an observation on 8/28/25 at 8:48 a.m., staff member D placed her clinical bag onto a chair in patient #2's living room. Staff member D had not placed a clean barrier onto the chair. Review of the agency's policy titled, Bag/equipment technique, last reviewed 10/18/24, showed: -... "4.1.7 Upon entering the patient's home, place the bag on a clean hard surface or hang from a door handle or other hook that will hold the weight of the bag. ..."

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure an agency-wide infection control program was maintained for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. Findings include: Review of the agency's Infection Control Program reflected the agency did not have an Infection Control program at the local branches that reflected the on-going collection of infections, lab work, analysis of appropriate use of antibiotics, or potential trends. During an interview on 8/27/25 at 11:00 a.m., with staff members A and B, staff member B stated the Infection Control was part of the quarterly QAPI meeting. The data in the quarterly QAPI meeting included the categories of infections, i.e. urinary, respiratory, skin, gastrointestinal, oral or blood. Staff member B stated each branch office attends the QAPI meeting submitting their local branch numbers of infections in each category to look for a trend and discuss potential education needs. Staff member B stated the agency branches did not collect data on lab work for the infections or look for trends at the branch level. Staff member B stated root cause analysis of infections was not done by the agency. Staff member B stated the agency did not have an Infection Control Performance Improvement Projects currently. Review of the agency's policy, Infection Surveillance Data Gathering, dated 10/21/24, reflected: -" ... 4.1 Data to include but is not limited to: 4.1.1 a) All patients who have suspected infection as noted on the Start of Care (SOC), post hospitalization history and physical or reported by the client, employee, family or outside information source if this will impact client/employee safety, and b) All patients with known or suspected infections acquired while receiving services from the agency and c) All employees with a known or suspected infectious/transmissible condition. 4.1.2 All patients who have had recent cultures/lab/physician intervention done for the following conditions: a) Urinary b) Respiratory c) Wound or skin lesion d) Gastrointestinal e) Oral or blood ... 4.1.4 A copy of all culture reports will be forwarded to the Branch Director (Clinical Manager) by the nurse or therapist receiving this information. Any patient reported infectious condition is to be reported to the Branch Director. The nurse, therapist or other health care worker involved in a patient's care will be held accountable for the appropriate and timely reporting and documentation of all suspected infectious processes to the Branch Director regardless of the availability of culture reports. Documentation will include the date the infection was detected, the patient's name, primary diagnosis, signs and symptoms, type of infection, pathogens identified, and treatment as disclosed by client. ..."

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure infection control training was completed on hire for 2 staff members (J and K) of 10 personnel files reviewed. Findings include: During review of the Human Resource education records and interview on 8/27/25 at 3:45 p.m., via Teams, staff member H stated the records showed staff members J and K had not completed the online Infection Control courses assigned to them. During an interview on 8/27/25 at 4:10 p.m., staff member B stated the agency was working on completing the education for all employees and was aware the agency was not currently up to date on the necessary training for infection control.

Participate in HHA-sponsored in-service CFR(s): 484.75(b)(9) Participation in HHA-sponsored in-service training. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure staff completed new hire in-service training for 4 staff members (E, I, J, and K) of 10 personnel files reviewed. Findings include: During review of the Human Resource education records and interview on 8/27/25 at 3:45 p.m., via Teams, staff member H stated the records showed staff members E, I, J and K had not completed the online new hire in-service courses assigned to them. During an interview on 8/27/25 at 4:10 p.m., staff member B stated the agency was working on completing the education for all employees and was aware the agency was not currently up to date on the necessary education.