Every finding on record at Essential Home Healthcare, Inc

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(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 LTC facilities at §483.73(a)(1):] 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)(1):] 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. * [For Hospices at §418.113(a)(2):] 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. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan, Agency policy, and staff interview, it was determined the Agency failed to ensure the Emergency Preparedness Plan was based on a facility-based and community-based risk assessment, utilizing an all hazards approach. This has the potential to affect all Pts. receiving services. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 8/3/21 at 3:00 PM. The plan lacked a facility-based and community-based risk assessment, using the all hazards approach. 2. The Agency policy titled "Emergency Preparedness Plan" was reviewed on 8/3/21 at 3:25 PM. The policy required: "...emergency preparedness plan is to include a documented facility-based and community-based risk assessment, utilizing an all-hazards approach. The plan will be developed to address how the Agency will deal with the identified potential events from the risk assessment..." 3. During an interview with the Administrator and the Director of Nursing on 8/4/21 at 1:20 PM, the Administrator confirmed the Agency did not complete a Hazard Vulnerability Risk Assessment.

Names and Contact Information CFR(s): 484.102(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).] 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, Agency policy, 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 was reviewed on 8/4//21 at 3:00 PM. The plan lacked a communication plan that meets the following requirements: Names and contact information for staff members, entities providing service under arrangement, Pt. Physicians, and Volunteers. 2. The Agency policy titled "Emergency Preparedness Plan" was reviewed on 8/3/21 at 3:25 PM. The policy required: "...The communication plan will include the name and contact information for the following: Staff, Entities providing services under arrangement, Patient's Physicians, and Volunteers..." 2. During an interview with the Administrator and Director of Nursing on 8/4/21 at 1:20 PM, the Administrator confirmed the above finding.

Recertification survey completed. Standard level deficiencies cited. A Focused Infection Control Survey (FIC) was conducted on 8/5/21. Standard level deficiency cited. Abbreviations: Pt./Pts. = Patient/Patients SOC = Start of Care SN = Skilled Nurse RN = Registered Nurse LPN = Licensed Practical Nurse PT = Physical Therapist OT = Occupational Therapist COTA= Certified Occupational Therapist Assistant HHA - Home Health Aide AM = Morning PM = Afternoon, Evening FIC = Focus Infection Control COVID-19 = Coronavirus 2019

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 that the Agency failed to ensure informed consents contained the frequency of visits. This was found in 3 of 7 (Pts. #2, 4 and 5) clinical records reviewed. Findings include: 1. The following clinical records were reviewed on 8/2/21 and 8/4/21 between 11:30 AM to 12:13 PM: Pt. #2 SOC: 07/08/21 Pt. #4 SOC: 04/29/21 Pt. #5 SOC: 06/10/21 The records lacked documentation of the Pt. consenting to the frequency of visits. 2. During an interview with the Administrator and the Director of Nursing on 8/4/21 at 2:30 PM, it was confirmed that the records lacked documentation on the patients' consents as to the frequency of visits to be provided.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: . A. Based on clinical record review and staff interview, it was determined the Agency failed to ensure Pts. were made aware of their out-of-pocket costs for services, if any, at the SOC. This was found in 7 of 7 (Pts. #5, 3, 2, 1, 4, 6, and 7) records reviewed. Findings include: 1. Pt. #5. SOC 6/10/21. Primary Diagnosis: Benign Prostate Hyperplasia without Lower Urinary Tract Symptoms. The clinical record was reviewed on 8/3/21 at 11:30 AM. The record contained a document titled "Home Health Care Agreement and Authorization," signed by Pt. #5 at the SOC. This form lacked information regarding the amount of charges, if any, Pt. #5 would be responsible to pay out-of-pocket for Agency services. 2. Pt. #3. SOC 5/4/21. Primary Diagnosis: Hypertensive Heart and Chronic Kidney Disease with Heart Failure. The clinical record was reviewed on 8/3/21 at 12:10 PM. The record contained a document titled "Home Health Care Agreement and Authorization," signed by Pt. #3 at the SOC. This form lacked information regarding the amount of charges, if any, Pt. #3 would be responsible to pay out-of-pocket for Agency services. 3. Pt. #2. SOC 7/8/21. Primary Diagnosis: Primary Generalized Osteoarthritis. The clinical record was reviewed on 8/3/21 at 2:30 PM. The record contained a document titled "Home Health Care Agreement and Authorization," signed by Pt. #2 at the SOC. This form lacked information regarding the amount of charges, if any, Pt. #2 would be responsible to pay out-of-pocket for Agency services. 4. Pt #1. SOC 4/9/21. Diagnosis: Ataxia following Cerebral Infarction. The clinical record was reviewed on 8/2/21 at 2:00 PM. The record included a document titled "Home Health Care Agreement and Authorization," signed by Pt. #1 at the SOC. This form lacked information regarding the amount of charges, if any, Pt. #1 would be responsible to pay out-of-pocket for Agency services. 5. Pt #4. SOC 4/29/21. Diagnosis: Essential Primary Hypertension. The clinical record was reviewed on 8/2/21 at 3:00 PM. The record included a document titled "Home Health Care Agreement and Authorization," signed by Pt. #4 at the SOC. This form lacked information regarding the amount of charges, if any, Pt. #4 would be responsible to pay out-of-pocket for Agency services. 6. Pt #6. SOC 2/22/21. Diagnosis: Hypertensive Heart and Chronic Kidney disease. The clinical record was reviewed on 8/4/21 at 11:00 AM. The record included a document titled "Home Health Care Agreement and Authorization," signed by Pt. #6 at the SOC. This form lacked information regarding the amount of charges, if any, Pt. #6 would be responsible to pay out-of-pocket for Agency services. 7. Pt #7. SOC 5/18/21. Diagnosis: Unilateral Primary Osteoarthritis. The clinical record was reviewed on 8/4/21 at 12:13 PM. The record included a document titled "Home Health Care Agreement and Authorization," signed by Pt. #7 at the SOC. This form lacked information regarding the amount of charges, if any, Pt. #7 would be responsible to pay out-of-pocket for Agency services. 8. During an interview with the Administrator and Director of Nursing on 8/4/21 at 1:20 PM, the Administrator confirmed the "Home Health Care Agreement and Authorization" forms lacked the amount of charges, if any, Pts. would be responsible to pay out-of-pocket for Agency services.

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 clinical record review and staff interviews, it was determined the Agency failed to ensure Pts. are screened for COVID-19, prior to providing Pt. care and services. This was found in 7 of 7 Pts. #1, 4, 6, 7, 5, 3, and 2) clinical records reviewed. Findings include: 1. Pt #1. SOC 4/9/21. Diagnosis: Ataxia following Cerebral Infarction. The clinical record was reviewed on 8/2/21 at 2:00 PM. The record included the HHA visit notes for services provided one to two times a week from 6/12/21 to 7/26/21. The record lacked documentation the HHA screened the Pt. for COVID-19 symptoms, prior to the visits indicated above. 2. Pt #4. SOC 4/29/21. Diagnosis: Essential Primary Hypertension. The clinical record was reviewed on 8/2/21 at 3:00 PM. The record included the HHA visit notes for services provided two times a week from 4/29/21 to 6/27/21 and 6/28/21 to 8/26/21. The record lacked documentation the HHA screened the Pt. for COVID-19 symptoms, prior to the visits indicated above. 3. Pt #6. SOC 2/22/21. Diagnosis: Hypertensive Heart and Chronic Kidney disease. The clinical record was reviewed on 8/4/21 at 11:00 AM. The record included the HHA visit notes for services provided two times a week from 2/22/21 to 4/22/21. The record lacked documentation the HHA screened the Pt. for COVID-19 symptoms, prior to the visits indicated above. 4. Pt #7. SOC 5/18/21. Diagnosis: Unilateral Primary Osteoarthritis. The clinical record was reviewed on 8/4/21 at 12:13 PM. The record included PT and OT visit notes for services provided one to two times a week from 5/18/21 to 7/16/21. The record lacked documentation the PT, OT, and the COTA screened the Pt. for COVID-19 symptoms, prior to the visits indicated above. 5. Pt. #5. SOC 6/10/21. Primary Diagnosis: Benign Prostate Hyperplasia without Lower Urinary Tract Symptoms. The clinical record was reviewed on 8/3/21 at 11:30 AM. The record contained SN notes dated 6/10/21, 6/29/21, 7/8/21, 7/13/21, and 7/26/21, indicating that the Pt. received SN services on these dates. The record lacked documentation that the SN screened the Pt. for signs and symptoms of COVID prior to these visits. The record also included weekly PT visit notes from 6/12/21 to 7/15/21, indicating that the Pt. received PT services on these dates. The record lacked documentation that the PT screened the Pt. for signs and symptoms of COVID prior to these visits. 6. Pt #3. SOC 5/4/21. Primary Diagnosis: Hypertensive Heart and Chronic Kidney Disease with Heart Failure. The clinical record was reviewed on 8/3/21 at 12:10 PM. The record contained an SN note dated 6/19/21, indicating that the Pt. received SN services on this date. The record lacked documentation that the SN screened the Pt. for signs and symptoms of COVID prior to this visit. The record also included twice weekly HHA visit notes from 6/6/21 to 7/26/21, indicating the HHA provided services on these dates. The record lacked documentation that the HHA screened the Pt. for signs and symptoms of COVID-19 prior to these visits. 7. Pt. #2. SOC 7/8/21. Primary Diagnosis: Primary Generalized Osteoarthritis. The clinical record was reviewed on 8/3/21 at 2:30 PM. The record contained an SN note dated 7/8/21, indicating that the Pt. received SN services on this date. The record lacked documentation that the SN screened the Pt. for signs and symptoms of COVID prior to this visit. The record also included a HHA visit note dated 7/8/21, as well as twice weekly HHA visit notes from 7/14/21 to 7/28/21, indicating the HHA provided services on these dates. The record lacked documentation that the HHA screened the Pt. for signs and symptoms of COVID-19 prior to these visits. 8. During the Focused Infection Control (FIC) interview with the Director of Nursing on 8/4/21 at 12:30 PM, the Director of Nursing stated staff are required to call the Pt./caregiver before the visit, and ask if they have a temperature, have any COVID symptoms, or have been around anyone with COVID. The staff member should then document this information in the narrative or under other/comments of the visit form. 9. During an interview with the Director of Nursing on 8/4/21 at 2:30 PM, the Director of Nursing confirmed the above findings.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: . A. Based on clinical record review, Agency policy, and staff interview, it was determined the Agency failed to ensure HHA's were supervised by a SN or other skilled professional at least every 14 days. This was found in 4 of 4 (Pts. #3, 2, 1, and 4) records reviewed, wherein the Pt. received Home Health Aide services. Findings include: 1. Pt. #3. SOC 5/4/21. Primary Diagnosis: Hypertensive Heart and Chronic Kidney Disease with Heart Failure. The clinical record was reviewed on 8/3/21 at 12:10 PM. The record contained documentation the HHA provided services to the Pt. twice weekly from 6/6/21 to 7/26/21. The record lacked documentation the SN/other skilled professional supervised the HHA during this time period (a total of 50 days without supervision). 2. Pt. #2. SOC 7/8/21. Primary Diagnosis: Primary Generalized Osteoarthritis. The clinical record was reviewed on 8/3/21 at 2:30 PM. The record contained documentation the HHA provided services to the Pt. on 7/8/21, and twice weekly from 7/14/21 to 7/28/21. The record lacked documentation the SN/other skilled professional supervised the HHA during this time period (a total of twenty days without supervision). 3. Pt #1. SOC 4/9/21. Diagnosis: Ataxia following Cerebral Infarction. The clinical record was reviewed on 8/2/21 at 2:00 PM. The record included the Home Health Aide visit notes for services provided one time a week from 6/12/21 to 7/26/21. The record lacked documentation an RN conducted any Home Health Aide Supervision (a total of 44 days without supervision). 4. Pt #4. SOC 4/29/21. Diagnosis: Essential Primary Hypertension. The clinical record was reviewed on 8/2/21 at 3:00 PM. The record included the Home Health Aide visit notes for services provided two times a week from 4/29/21 to 6/27/21. The record lacked documentation an RN conducted any Home Health Aide Supervision (a total of 50 days without supervision). 5. The Agency policy titled "Duties and Responsibilities (RN/LPN)" was reviewed on 8/4/21 at 11:45 AM. The policy required: "...Supervisory Visits...HHA - every two weeks..." 6. During interviews with the Administrator and Director of Nursing on 8/4/21 at 1:20 PM and 2:30 PM, the Director of Nursing confirmed the lack of Home Health Aide supervision.