Every finding on record at Elite Healthcare Providers, LLC

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), §485.625(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: A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure it developed strategies for addressing emergency events identified by its Hazard Vulnerability Risk Assessment. Findings include: 1. The Agency's Emergency Preparedness plan was reviewed on 10/26/21 at 2:00 PM. The plan contained a Hazard Vulnerability Assessment, last updated 5/17/21. This assessment included the following emergency events were rated at a "2" (moderate probability of occurrence): Ice/Snow; Fire; Tornado; Civil Disturbance; and Environmental/Altered Air Quality. The plan lacked strategies for addressing these events, should they occur. 2. During an interview with the Administrator and Director of Nursing on 10/27/21 at 2:10 PM, both confirmed the above findings.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined that the Agency failed to have a communication plan that included the required names and contact information. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan, last updated 5/17/21, was reviewed on 10/26//21 at 2:00 PM. The plan lacked a communication plan that contained the name and contact information for E #1, 6, and 9, as well as Pt. Physicians, and Volunteers. 2. During an interview with the Administrator and the Director of Nursing on 10/27/21 at 2:10 PM, both confirmed the above findings.

Recertification survey completed. Standard Level deficiencies cited. Abbreviations: x = time # = number % = percent W/wk = week = greater than Eval = Evaluation PRN = as needed SN = Skilled Nurse POC = Plan of care tab/TABS = Tablets SOC = Start of care mg/MG = milligram(s) PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening ER = Extended Release Pt./ Pts. = Patient/Patients ST = Speech Therapy/Therapist PT = Physical Therapy/Therapist PTA = Physical Therapy Assistant OT = Occupational Therapy/Therapist

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: A. Based on review of clinical records and staff interview, it was determined the Agency failed to ensure informed consents contained the title of the disciplines that would be providing service to the Pt., as well as the frequency of visits. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) records reviewed. Findings include: 1. The following clinical records were reviewed from 10/25/21 at 1:30 PM to 10/27/21 at 10:30 AM: Pt. #1 SOC: 7/31/21 Pt. #2 SOC: 7/31/21 Pt. #3 SOC: 7/29/21 Pt. #4 SOC: 9/2/21 Pt. #5 SOC: 9/4/21 Pt. #6 SOC: 9/30/20 Pt. #7 SOC: 6/30/21 The records lacked documentation these Pts. consented to receive service from the SN and/or Skilled Therapist, as well as the frequency of visits. 2. During interviews with the Administrator and the Director of Nursing on 10/27/21 at 12:10 PM and 2:10 PM, both confirmed the above findings.

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. This was found in 3 of 7 (Pts. #3, 5 and 6) clinical records reviewed. Findings include: 1. Pt. #3. SOC 7/29/21. Diagnoses: Hemiplegia Following Infarction Affecting Left Nondominant Side and Unspecified Painful Micturition. The clinical record was reviewed on 10/26/21 at 10:30 AM. The record contained the “Physician Face To Face Encounter” form dated 7/24/21. The SOC visit was conducted by the RN on 7/29/21 (5 days after the Physician’s order/referral). The record lacked documentation the Pt. was discharged from an inpatient facility or had a Physician ordered SOC date. The record also lacked the date the Agency received the referral. It cannot be determined whether the Agency initiated service within 48 hours of receipt of the referral. 2. Pt. #5. SOC 9/4/21. Diagnoses: Lumbar Region Other Intervertebral Disc Degeneration, Generalized Muscle Weakness and History of Falling. The clinical record was reviewed on 10/26/21at 11:35 PM. The record contained the “Physician Face To Face Encounter” form dated 8/9/21. The SOC visit was conducted by the RN on 9/4/21 (26 days after the Physician’s order/referral). The record lacked documentation the Pt. was discharged from an inpatient facility or had a Physician ordered SOC date. The record also lacked the date the Agency received the referral. It cannot be determined whether the Agency initiated service within 48 hours of receipt of the referral. 3. Pt. #6. SOC 9/30/20. Diagnoses: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Hypertensive Heart Disease with Heart Failure. The closed clinical record was reviewed on 10/26/21 at 9:35 AM. The record contained a “Physician Face To Face Encounter” form dated 9/19/20, and faxed to the Agency on 9/20/20. The SOC visit was conducted by the RN on 9/30/20 (10 days after receipt of the Physician’s referral). The Agency failed to initiate service within 48 hours of receipt of the referral. 4. During an interview with the Administrator and Director of Nursing on 10/17/21 at 12:10 PM, both confirmed the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date or receipt of the referral.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: A. Based on clinical record review, Agency policy review and staff interview, it was determined the Agency failed to ensure Pt. immunization screening was conducted, as required by the Agency. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 10/25/21 at 1:30 PM to 10/27/21 at 10:30 AM: Pt. #1. SOC 7/31/21. Pt. #2. SOC 7/31/21. Pt. #3. SOC 7/29/21. Pt. #4. SOC 9/2/21. Pt. #5. SOC 9/4/21. Pt. #6. SOC 9/30/20. Pt. #7. SOC 6/30/21. The records contained a form titled: “Consent For Influenza, Pneumonia & Shingles Vaccine” which included sections for Influenza and Pneumonia vaccine inquiries, these sections were left blank. The forms lacked documentation indicating whether the Influenza and Pneumonia vaccines were offered, arranged and/or administered. 2. The Agency policy titled, “Influenza and Pneumococcal Vaccination Policy For Patients/Clients” was reviewed on 10/28/21 at 11:18 AM. The policy required: “1...a... Patient will have to complete Influenza vaccination screening form... 3. Pneumococcal Vaccine... agency will make the necessary arrangement...4. Patient vaccination status will be updated on patient records.” 3. During the entrance interview with the Administrator and Director of Nursing on 10/25/21 at 9:30 AM, the Director of Nursing stated that during the SOC visit, the RN inquire about the patient’s Influenza and Pneumococcal Pneumonia vaccine status, this information is documented on Agency’s Vaccine form. 4. During an interview with the Administrator and Director of Nursing on 10/27/21 at 12:10 PM and 2:10 PM. The Director of Nursing confirmed the SN failed to ensure Pt. immunization screening was conducted at the SOC, as required by the Agency.

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: A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure staff screen Pts. for COVID-19, prior to providing Pt. care and/or services. This was found in 3 of 7 (Pts. 6, 7 and 4) clinical records reviewed. Findings include: 1. Pt. #6. SOC 9/30/20. Diagnoses: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Hypertensive Heart Disease with Heart Failure. The closed clinical record was reviewed on 10/26/21 at 9:35 AM. The record contained the Home Health Aide visit notes dated 12/15/20, 12/21/20, 1/4/21, 1/7/21 and 1/11/21, indicating care was provided. The record lacked documentation the Home Health Aide screened the Pt. for COVID-19 symptoms, prior to providing Pt. care on the days indicated above. 2. Pt. #7. SOC 1/12/21. Primary Diagnosis: Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris. The closed clinical record was reviewed on 10/27/21 at 9:30 AM. The record contained the Home Health Aide visit notes dated 7/17/21, 7/22/21, 7/29/21, 8/5/21 and 8/27/21, indicating care was provided. The record lacked documentation the Home Health Aide screened the Pt. for COVID-19 symptoms, prior to providing Pt. care on the days indicated above. 3. Pt. #4. SOC 9/2/21. Primary Diagnosis: Encephalopathy, Unspecified. The clinical record was reviewed on 10/26/21 at 11:00 AM. The record contained documentation the OT provided service on 9/11/21 and 9/30/21. The record lacked documentation the OT screened the Pt. for signs and symptoms of COVID-19, prior to these visits. The record also included documentation the ST provided service on 9/10/21 and 9/15/21. The record lacked documentation the ST screened the Pt. for signs and symptoms of COVID-19, prior to these visits. 4. During interviews with the Administrator and Director of Nursing on 10/27/21 at 12:10 PM and 2:10 PM, both confirmed the above findings. The Director of Nursing stated all clinicians should screen the Pt. for signs and symptoms of COVID-19 prior to home visits, and document the results of those screenings in the Patient’s medical record.

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: A. Based on a review of clinical records and staff interview, it was determined the Agency failed to provide services as required by the POC. This was found in 4 of 7 (Pts. #1, 4, 3 and 5) clinical records reviewed. 3. Pt. #3. SOC 7/29/21. Diagnoses: Hemiplegia Following Infarction Affecting Left Nondominant Side and Unspecified Painful Micturition. The clinical record was reviewed on 10/26/21 at 10:30 AM. The record contained the POC for the certification period of 7/29/21 to 9/26/21 which required: “SN to instruct patient/caregiver on bladder training program.” The weekly SN visit notes dated 8/5/21, 8/10/21, 8/20/21, 8/27/21, 9/1/21, 9/8/21, 9/16/21 and the recertification comprehensive assessment dated 9/23/21 lacked documentation the SN instructed the Pt. or caregiver on a bladder training program. The POC effective 9/27/21 required: “SN Frequency: 1 W 9”. As of 10/26/21, the record lacked documentation the SN provided service during the weeks of 10/3/21 to 10/9/21 and 10/10/21 to 10/16/21. 4. Pt. #5. SOC 9/4/21. Diagnoses: Lumbar Region Other Intervertebral Disc Degeneration, Generalized Muscle Weakness and History of Falling. The clinical record was reviewed on 10/26/21at 11:35 PM. The record contained the POC effective 9/4/21 required: “PT Frequency: Evaluation, and, treatment”. The PT evaluation was conducted on 9/30/21 (26 days after the SOC visit). The record lacked documentation the PT conducted the evaluation within 48 hours after the SOC, as required by the Agency. 5. During an interview with the Director of Nursing on 10/27/21 at 9:32 AM, the Director of Nursing stated: “Once the nurse complete the SOC visit, it is expected the other disciplines start providing service within 48 hours of the SOC”. 6. During an interview with the Administrator and Director of Nursing on 10/17/21 at 12:10 PM and 2:10 PM. The Director of Nursing confirmed the staff failed to provide service as indicated on the POC. Findings include: 1. Pt. #1. SOC 7/31/21. Primary Diagnosis: Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 10/25/21 at 1:30 PM. The record contained the POC effective 7/31/21 to 9/28/21, which contained the Physician’s order: “Notify Physician of vital sign parameters out of range: Blood Sugar, Random: Greater than (>) 250…” The record included the SN visit note dated 9/10/21, which contained documentation the Patient’s random blood sugar level was 261. The record also contained the SN visit note dated 9/16/21, which included documentation the Patient’s random blood sugar level was 296. The record also included the SN recertification visit note dated 9/24/21, which contained documentation the Patient’s random blood sugar level was 291. The record lacked documentation the Physician was notified of the Patient’s high random blood sugar levels on these dates. The record also included the Physician’s order dated 9/30/21: “Please order walker and Physical Therapy.” The record lacked documentation the Pt. was subsequently evaluated by the PT, or a Physician’s order to cancel the PT evaluation. 2. Pt. #4. SOC 9/2/21. Primary Diagnosis: Encephalopathy, Unspecified. The clinical record was reviewed on 10/26/21 at 11:00 AM. The record contained the POC effective 9/2/21 to 10/31/21, which included the Physician’s order: “ST Frequency: Eval.” The record included documentation the ST evaluation was completed on 9/10/21, 8 days later. This POC also contained the Physician’s order: “PT Frequency: Eval.” The record included documentation the PT evaluation was completed on 9/9/21, 7 days later. The record also included the “Physical Therapy Plan of Care,” dated 9/9/21, which contained “Visit Frequency: 1WK1, 2WK3.” The record lacked documentation the Pt. received either of the two PT visits ordered for the week of 9/12/21 to 9/18/21. There was no documentation the Physician was notified of these missed visits. The record also included a PTA “Missed Visit” note, dated 9/22/21, which contained “…daughter canceled therapy and reported Patient is doing well and may not need Physical Therapy...” The record contained documentation the Physician was faxed notification of the 9/22/21 missed visit and the family’s cancellation of PT service on 9/29/21, 7 days later. This POC also included the Physician’s order: “OT Frequency: Eval.” The record contained documentation the OT evaluation was completed on 9/11/21, 9 days later.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: A. Based on clinical record reviews, observations and interviews during home visits, Agency policy review and staff interview, it was determined the Agency failed to ensure the medications listed in the clinical record were complete and/or accurate. This was found in 3 of 7 (Pts. #1, 2 and 3) clinical records reviewed. 3. Pt. #3. SOC 7/29/21. Diagnoses: Hemiplegia Following Infarction Affecting Left Nondominant Side and Unspecified Painful Micturition. The clinical record was reviewed on 10/26/21 at 10:30 AM. The record contained the form titled, “Medication Profile” which included: “Metoprolol Succinate 50 MG Oral Tablet, Extended Release 1 tab 2x a day By mouth”. A home visit was conducted with E #11 on 10/27/21 at 2:00 PM. During the home visit, the patient’s medications were observed and an interview was conducted with the caregiver/homemaker that provided a medication dated “06/26/21”, the bottle was labeled: “Metoprolol ER Succinate 50 MG TABS Take 1 and ½ Tablets by mouth every day”. The caregiver stated, “The doctor changed the dose several months ago.” As of 10/26/21, the Medication Profile lacked the correct dosed of Metoprolol Succinate ER. 4. During an interview with the Administrator and Director of Nursing on 10/27/21 at 2:10 PM and 10/28/21 at 10:20 AM. The Director of Nursing confirmed the SN failed to ensure the Medication Profiles indicated above were accurate. Findings include: 1. Pt. #1. SOC 7/31/21. Primary Diagnosis: Type 2 Diabetes Mellitus with Hyperglycemia. The clinical record was reviewed on 10/25/21 at 1:30 PM. The record contained a Medication Profile, which was printed on 10/25/21. A home visit was conducted on 10/25/21, along with E #4. During this home visit, the Pt. #1’s medications were observed and compared to the Medication Profile. The Medication Profile included the Physician’s order for “Farxiga 10 mg oral tablet 1 tab daily by mouth,” and “Oxybutynin 5 mg oral tablet 1 tab daily by mouth.” Pt. #1 stated “I’m not taking either of these (medications) for at least a month or more.” Pt. #1 also presented a bottle of Meclizine 25 mg tablets, and stated “I take “1 or 2 of these, if I need to, for a long time.” The medication profile was inaccurate. 2. Pt. #2. SOC 7/31/21. Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 10/26/21 at 10:15 AM. A home visit was conducted on 10/25/21 at 3:00 PM, along with E #10. During this home visit, Pt. #2’s medications were compared with the Medication Profile, printed on 10/25/21. This Medication Profile contained a Physician’s order for “Omeprazole 20 mg oral delayed release capsule 1 cap daily by mouth.” Pt. #2 stated “I stopped taking that about a year ago.” Pt. #2 then presented a bottle of Ferosul 325 mg tablets, and stated “I take one of these every day—for a long time.” The Medication Profile lacked a Physician’s order for Ferosul. The Medication Profile was inaccurate.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: A. Based on review of clinical records and staff interview, it was determined the Agency failed to ensure the Physician was sent a copy of the Discharge Summary. This was found in 2 of 2 (Pts. #6 and 7) closed/discharged clinical records reviewed. Findings include: 1. Pt. #6. SOC 9/30/20. Diagnoses: Type 2 Diabetes Mellitus with Diabetic Polyneuropathy and Hypertensive Heart Disease with Heart Failure. The closed clinical record was reviewed on 10/26/21 at 9:35 AM. The record/Agency lacked documentation a copy of the Discharge Summary was sent to the Physician. The Pt. was discharged from the Agency on 1/21/21. 2. Pt. #7. SOC 1/12/21. Primary Diagnosis: Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris. The closed clinical record was reviewed on 10/27/21 at 9:30 AM. The record/Agency lacked documentation a copy of the Discharge Summary was sent to the Physician. The Pt. was discharged from the Agency on 10/21/21. 3. During an interview with the Administrator and Director of Nursing on 10/17/21 at 12:10 PM. The Director of Nursing stated: “I have no proof that I sent it”. During the same interview, the Administrator and Director of Nursing confirmed the above findings.