Every finding on record at Elite Home Health Care, LLC

A Medicare Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Nevada Department of Health and Human Services. The survey conducted from 08/08/2022 to 08/10/2022 resulted in a finding of standard level deficiencies respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

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: Based on interview, review of documents, and review of agency policy, the agency failed to ensure completion of an updated all-hazards risk assessment on which to base their Emergency Preparedness Plan. Failure to identify and plan for the most likely and most serious hazards likely to befall the agency could cause the facility to be unprepared for those emergencies, placing all 50 patients served by this agency at risk of harm. Findings include: Review of the agency’s “Emergency Preparedness [EP] Program 2022,” revealed a blank form titled, “Hazard Vulnerability Analysis [HVA].” During an interview with the agency Administrator on 08/10/2022 at 11:35 AM, the Administrator was responsible for the EP Program at the agency. During the interview, the EP Program document was reviewed. The Administrator provided the most recent completed HVA, which was dated 12/14/2018. The Administrator confirmed this was the last time the HVA had been reviewed and agreed that it had not been reviewed and/or updated as needed or at least every two years with the review of the entire EP Program. Further review of the agency’s “EP Program 2022,” revealed, “The Agency's Emergency Preparedness Program consists of Hazard Vulnerability Analysis and All Hazard Mitigation Plan, and Emergency Management Plan. The Hazard Vulnerability Analysis and All Hazard Mitigation Plan are designed so that the Agency can evaluate their level of risk and preparedness for a variety of hazardous events. A hazard vulnerability assessment is the first step in emergency planning for the Agency…The agency developed and maintains written emergency management plan describing process for disaster readiness and emergency management and implements it when appropriate…The organization established priorities among the potential emergencies and the organization's role in relation to a community-wide emergency management program.”

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: Based on document review, staff interview, and review of agency policies and procedures, the agency failed to ensure the staff emergency contact information was reviewed and updated as needed at least every two years. Failure to maintain current contact information could lead to delays in contacting staff assistance with emergency procedures, placing all 50 patients receiving services from this agency at risk. Findings include: Review of the agency’s “Emergency Preparedness [EP] Program 2022,” revealed the EP Program contained no staff contact list. The EP Program stated it would maintain an “Emergency On-call Book with Staff and Patient Information.” Review of the “Emergency On-call Book,” revealed it was dated 2019. During an interview with the agency Administrator on 08/10/2022 at 11:35 AM, the EP Program and On-call Book were reviewed with the agency Administrator, who was responsible for the EP Program. The Administrator confirmed the staff list with contact information had not been updated since 2019 and added that most of the staff listed in the On-call Book were no longer employed by the agency. The Administrator stated that most of the 14 staff members currently employed by the agency were new hires and were not listed in the On-call book at the time of the survey. The Administrator stated understanding of the requirement to review and update the staff contact list as needed and at least every two years. Review of the agency’s “EP Program 2022,” revealed, “The agency developed and maintains written emergency management plan describing process for disaster readiness and emergency management, and implements it when appropriate…the emergency response is initiated by the Administrator or designee and ends by the Administrator or designee…all agency staff and appropriate vendors are notified using Pyramid Phone Communication Plan…The Director of Patient Care Services and secretary will call the office and list the employees available for assistance then come to the office. Upon arrival, every five (5) minutes, secretary will try those employees not found with the first call attempt and notify the disaster supervisors of any other employees available to be on standby. Once the Director of Patient Care Services have called and put staffs on alert, he/she may also function as an Emergency Supervisor.” Review of the agency policy titled, “Emergency Operations Plan and Policies,” last revised June 2017, revealed, “The Agency has developed and maintains an emergency preparedness plan and policies that are reviewed and updated at least annually…the Agency will follow up by telephone with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services...The Agency will track patients and staff by telephone or in person during an emergency.” Review of the agency EP Plan policy titled, “Communication Plan and Policy for Emergency Operations plan (EOP),” last revised 2017, revealed, “The Agency has developed and maintains an emergency preparedness communication plan that complies with federal, state and local laws. The communication plan is reviewed and updated at least annually. The communication plan includes the following: Names and contact information for the following: Staff.”

A Medicare Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of Nevada Department of Health and Human Services. The survey conducted from 08/08/2022 to 08/10/2022 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.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, policy review, and interview, the Home Health Agency (HHA) failed to review patient medications during home visits, notify the physician of any changes, or update the medication list for one of three patients (Patient (P)1) for whom home visits were completed. The failure to review medications the patient was taking had the potential to result in significant drug interactions, duplicate drug therapy, or unrecognized noncompliance with physician ordered drug therapy for all patients whose medications are not reviewed during home visits. Findings include: Review of an agency policy titled, "Medication Profile," dated October 2014, revealed, "Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications … Deviations from taking medications as ordered will be documented in clinical notes, and the physician will be notified." During a home visit observation on 08/08/2022 at 1:00 PM, review of the medication list with P1 and family members who were present, after the Registered Nurse (Administrator) left the home, revealed P1 was no longer taking famotidine (used to treat heartburn), amiodarone (used to treat an irregular heartbeat), and Eliquis (blood thinner used to prevent blood clots). P1 did not remember exactly when the patient stopped taking these medications. The medication list provided by the agency included these medications as current. During an interview on 08/08/2022 at 3:45 PM, the Administrator confirmed the medication list had not reviewed or updated and the physician had not been notified about any changes in medication. The Administrator stated, "This should be done at every visit."

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review, staff interview, and review of the agency's policies and procedures, the agency failed to ensure Physical Therapy (PT) services were initiated as ordered by the provider for three of four patient records that included PT orders (Patient (P)4, P5, and P8). Findings include: 1. Review of P4’s electronic medical record (EMR) revealed a Start of Care (SOC) date of 06/12/2022 with a diagnosis of pneumonia. Review of the initial “Plan of Care” (POC), in the “485/Plan of Care” section of the EMR, revealed a provider order for “Physical Therapy [PT] evaluation and treatment: plan of treatment, frequency and duration to be determined post evaluation.” Review of P4’s “Notes” in the EMR for the certification period of 06/12/2022 through 08/10/2022 revealed the first entry by PT was dated 07/09/2022, more than three weeks after the order date. The title of the note was, “PT Initial Evaluation.” 2. Review of P5’s EMR revealed a SOC date of 06/12/2022 with a diagnosis of multiple sclerosis. Review of the initial “POC” in the “485/Plan of Care” section of the EMR, revealed a provider order for “PT evaluation and treatment: plan of treatment, frequency and duration to be determined post evaluation.” Review of P5’s “Notes” in the EMR for the certification period of 06/12/2022 through 08/10/2022 revealed the first entry by PT was dated 07/09/2022, more than three weeks after the order date. The title of the note was, “PT Initial Evaluation.” 3. Review of P8’s EMR revealed a SOC date of 06/07/2022 with a diagnosis of multiple sclerosis. Review of the initial “POC” in the “485/Plan of Care” section of the EMR, revealed a provider order for “PT evaluation and treatment: plan of treatment, frequency and duration to be determined post evaluation.” Review of P8’s “Notes” in the EMR for the certification period of 06/07/2022 through 08/05/2022 revealed the first entry by PT was dated 07/09/2022, more than three weeks after the order date. The title of the note was, “PT Initial Evaluation.” During an interview with the Quality Assurance Manager (QA) on 08/09/2022 at 3:30 PM, the EMRs for P4, P5 and P8 were reviewed. The QA confirmed the PT evaluation had been completed for these patients’ weeks after the ordered SOC date. The QA was unable to find any documentation or supplemental providers’ orders indicating the rationale for the delay in conducting the PT evaluation and agreed the agency had not followed the provider’s plan of care. The most current policy for Plan of Care was requested at this time. During a joint interview with the agency Administrator and QA on 08/09/2022 at 3:45 PM, both agreed agency expectation was for the providers’ orders for an evaluation to be completed within 72 hours of issue or to document a rationale for the delay in the medical record. The Administrator was unable to explain why the delay had taken place and stated, “The system to notify our contractors failed.” Review of the agency policy titled, “Admission Criteria and Process,” dated October 2014, revealed, “A patient will be accepted for care based on consideration. Consideration will be given to the adequacy and suitability of organization personnel, resources lo provide the required services, and the reasonable expectation that the patient's medical, nursing, rehabilitative, and social needs can be adequately met in the patient's place of residence…the Clinical Supervisor will assign clinical organization personnel to conduct initial assessments of eligibility for services within 72 hours of acceptance of referral information and/or discharge from referring facility.”

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, observation, and interview, the Home Health Agency (HHA) failed to ensure its policy regarding the use of Personal Protective Equipment (PPE) was followed during one of three patient (Patient (P)1) home visits. Failure to wear a face mask had the potential to spread the COVID-19 virus. Findings include: Review of an undated agency policy titled, "COVID-19 Policy and Procedure," revealed, "[Name of agency] goal is to prevent the transmission of COVID-19 in the workplace(s) … [Name of agency] will provide, and ensure that employees wear, face masks or a higher level of respiratory protection." During an observation on 08/08/2022 at 1:00 PM at the home of P1, the Registered Nurse (Administrator) did not wear a face mask during the entire visit and completion of the patient physical assessment. During an interview on 08/08/2022 at 3:45 PM, the Administrator confirmed not wearing a face mask while providing care to P1. Administrator stated, "I should have. I know the patient very well and I did not feel COVID-19 was a risk."

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 record review and interview, the Home Health Agency (HHA) failed to monitor, manage, and maintain the equipment used to access the web-based electronic medical record (EMR). The use of staff owned personal computers and cell phones to access the EMR had the potential to compromise personal patient information and could affect all patients currently receiving services from the HHA, and all patients who have received past services. Findings include: Surveyor was provided a log in and password to access the EMR. It was observed the log-in and password used to access the web based EMR could be saved. It was also observed patient information could be saved to the computer desktop and accessed outside of the web based EMR. During an interview on 08/08/2022 at 3:45 PM, the Administrator stated the agency did not provide laptop computers, tablets, or any type of electronic device for staff to use to access the EMR. The Administrator stated, "They use their own computers when they get home." The Administrator confirmed the agency was not able to monitor personal devices used to access the EMR to ensure patient information was not compromised and the agency was not able to manage, account for, or maintain the equipment that could access patient information. The Administrator stated the agency did not have a policy that addressed the use of personal devices to access the web based EMR.