Every finding on record at Evercare Home Health, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey at the new agency address located at 315 W. Verdugo Ave. Suite 100, Burbank, CA 91502 Old Address: 14540 Victory Blvd., Ste 229 Van Nuys, CA 91411 New Address: 315 W. Verdugo Ave. Suite 100 Burbank, CA 91502 Representing the California Department of Public Health: Surveyor ID: 44916, Health Facilities Evaluator Nurse Surveyor ID: 44749, Health Facilities Evaluator Nurse Surveyor ID: 44290, Health Facilities Evaluator Nurse Unduplicated Admissions - 126 Active Patients - 33 Sample Size - 7 Home Visits - 2 A visit was made to Evercare Home Health for the purpose of determining compliance with the California Code of Regulations, Title 22, for Home Health Agencies. The home health agency was approved for the change of location effective 11/10/2022

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review, the home health agency (HHA) failed to ensure the emergency preparedness (EP, the steps taken to make sure patients and staffs are safe before, during and after an emergency or natural disaster) plan/drill for field staff was completed on an annual basis. This failure had the potential to result in a lack of staff knowledge to respond effectively should an emergency/disaster situation occur. On 6/30/23 at 1 p.m., a review of the HHA's "Emergency preparedness Plan" revealed that on 3/22/23 the Chief Executive Officer of the HHA called an earthquake drill. When asked to provide the sign in sheet for all 13 employees, both office and field staff, the HHA could not provide the in-service sign in sheet on the date provided the HHA conducted their drill. On 6/30/23 at 3 p.m., during an interview with the Field Nurse Supervisor (FNS), the FNS stated she started working for the agency last 5/23/2023 and she did not know if they had conducted a recent emergency preparedness drill. During a concurrent interview with the office personnel (OP), OP stated they have not conducted an EP drill since she started working there. A review of the home health agency's policy titled, "Emergency Management Plan", indicated, the HHA's orientation and education program is for those who participate in implementing the plan. Staff shall attend orientation upon hire and an annual update of their specific roles and responsibilities and the skills they require to perform their duties during an emergency. In-service education shall be given on the back up communication system and obtaining supplies /equipment in the event of an emergency. The HHA's Emergency Management Plan shall be updated and documented at least annually and as needed. The safety director is responsible for the In-servicing staff at the organization-wide Emergency Operations Plan. The safety director shall be responsible for reviewing, documenting and updating the HHA's emergency preparedness training and testing program annually and as needed.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at the new agency address located at 315 W. Verdugo Ave. Suite 100, Burbank, CA 91502 Old Address: 14540 Victory Blvd., Ste 229 Van Nuys CA 91411 New Address: 315 W. Verdugo Ave. Suite 100 Burbank CA 91502 Representing the California Department of Public Health: Surveyor ID: 44916, Health Facilities Evaluator Nurse Surveyor ID: 44749, Health Facilities Evaluator Nurse Surveyor ID: 44290, Health Facilities Evaluator Nurse Unduplicated Admissions - 126 Active Patients - 33 Sample Size - 7 Home Visits - 2 A visit was made to Evercare Home Health for the purpose of determining compliance with the California Code of Regulations, Title 22, for Home Health Agencies. The home health agency was approved for the change of location effective 11/10/2022 Old Address: 5810 Monterey Road Los Angeles CA 90042 New Address: 2443 Atlantic Ave. Long Beach CA 90806 Office

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, interview and record review, the Home Health Agency (HHA) failed to maintain an accurate, and current medication profile for 3 of 7 patients (Patients 1, 2 and 3). This failure had the potential to result in placing the patients at risk for medication errors and adverse drug reactions. A review of Patient 3’s Plan of Care for certification period 5/14/23 to 7/12/23 indicated that they had a SOC date of 3/15/23. Patient 3 had diagnoses which included hypertensive heart disease (high blood pressure), atherosclerotic heart disease (build up of fats and cholesterol in the walls of arteries [blood vessels] causing obstruction of blood flow and osteoarthritis (flexible tissue at the ends of bones wears down causing pain and decreased movement). Patient 3 was to have Skilled Nursing (SN) visits once a week for nine weeks and the SN was to do medication reconciliation every visit. A review of Patient 3’s medication profile dated 5/12/23, indicated that Patient 3 was taking the following medications… 1. Cyclobenzaprine (muscle relaxant) 10 milligrams (mg: unit of measurement)1 tablet by mouth once a day. 2. Atenolol (blood pressure medication) 25 mg, 1 tablet by mouth twice a day. 3. Telmisartan/Hydrochlorothiazide (blood pressure medication) 40-12.5 mg, 1 tablet by mouth once a day. 4. Ibuprofen (pain medication) 600mg, 1 tablet by mouth twice a day as needed. 5. Vitamin D2 (supplement) 1.25mg, 1 tablet by mouth once a week. 6. Atorvastatin (cholesterol medication) 10mg, 1 tablet by mouth once a day. 7. Vitamin B6 (supplement) 50mg, 1 tablet by mouth twice a day. 8. Pantoprazole (medication to decrease stomach acid) 40mg, 1 tablet by mouth once a day. During Patient 3’s home visit, conducted on 6/30/23, at 10 am with Licensed Vocational Nurse 2 (LVN 2), Patient 3’s medications were reviewed, and the following discrepancies were found… 1. Patient 3 was no longer taking Cyclobenzaprine, Vitamin D2, Vitamin B6 and Pantoprazole. 2. Patient 3 had two new medications … a. Famotidine (medicine to decrease stomach acid) 20mg, 1 tablet by mouth daily. b. Baclofen (muscle relaxant) 10mg, 1 tablet by mouth once a day During an interview with LVN 2, she stated that she had already done the medication reconciliation with the new updates to the medication. LVN 2 stated that she communicated the changes with the HA office and she also documented in her notes. LVN 2 stated that the office is supposed to update the medication profile. Patient 1’s medication profile list that was in her home health folder, along with the medication bottles was reviewed with LVN 2 and it had the following updates documented by LVN 2… 1. Cyclobenzaprine, Vitamin D2 and vitamin B6 was discontinued on 6/23/23 2. Pantoprazole was discontinued on 6/7/23 3. Famotidine started on 6/7/23 4. Baclofen was stated on 6/23/23 During a concurrent interview and record review on 6/30/23, at 2:11pm, the Registered Nurse Supervisor (RNS) reviewed Patient 3’s records and found communications for the medication changes. RNS stated that the medication profile should have been updated within 24 hours of receiving the new med orders, but no later than the next scheduled home visit. RNS stated that it is important to have a medication profile that is up to date to make sure the patient is taking the correct medications. A review of the HHA's policy titled " Medication Profile", (undated), stated that patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. Visiting personnel will do medication reconciliation every visit. This reconciliation is done to avoid medication errors such as omissions, duplications, or dosing errors. Deviations in taking medications as ordered will be documented in clinical notes and the physician will be notified. 1. A review of Patient 1's (P1) Patient Profile Information indicated, a start of care (SOC) date of 3/29/23, with a certification period of 5/28/23 to 7/26/23. P1's diagnosis included heart failure unspecified (A chronic condition in which the heart doesn't pump blood as well as it should) hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) has a history of 2 coronary stents (A coronary stent is a tube-shaped device placed in the coronary arteries that supply blood to the heart, to keep the arteries open in the treatment of coronary heart disease) and 2 episodes of stroke (occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) and anxiety disorder (Intense, excessive, and persistent worry and fear about everyday situations. Fast heart rate, rapid breathing, sweating, and feeling tired may occur). Skilled nurse (SN)visits twice a week for 2 weeks and once a week for seven weeks. SN to perform every home visit temperature, heart rate, blood pressure levels; with accurate documentation, patients caregiver is competent taking vital signs; scale pain 0-10, implement pain relief measures and its effectiveness; assess/monitor for medication effectiveness, possible adverse effects, duplication. SN to continue to report to Medical Doctor (MD) any changes or unfavorable response/reactions to treatments or interventions, medication adverse effects and hospitalization. A home visit was conducted on 6/30/23 at 10:15 a.m., with Licensed Vocational Nurse 1(LVN 1). Patient 1 and 2 which were husband and wife. P1 and P2 was observed sitting in the living room area, both were alert and oriented to name, place, and time, not in any respiratory distress, walks around with a cane. Bothe P1 and P2 has periods of restlessness and anxiety. During a review of P1's medications currently taking reconciling, P1 was observed to start pacing inside develop anxiety. P1 stood up and grabbed a small bottle in the kitchen counter and popped 1 white pill in her mouth. When asked what the bottle was, P1 stated it was nitroglycerin. P1 stated she was experiencing mild chest palpitations and taking nitroglycerin helps her reduce her anxiety. During a review of P1's medications currently taking reconciling with the medication profile on 6/30/23, at 10:30 a.m., indicated the following medications were not updated in the medication profile: 1. Advair 250 mcg/50mcg (micrograms a unit of measurement) 2 puffs as needed for SOB not on list 2. Nitroglycerin Sublingual (0.4 mg (milligram -a unit of measurement) 1 tablet as needed for chest pain was not listed on the medication profile. 3. Emergen-C 1000 mg 1 packet daily as supplement is also not listed on the medication profile. 2. A review of Patient 2's (P2) Patient Profile Information indicated, an SOC date of 3/29/23, with a certification period of 5/28/23 to 7/26/23. P2's diagnosis included hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) atrial fibrillation (is a quivering or irregular heartbeat, or arrhythmia) anxiety disorder and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Skilled nurse (SN)visits twice a week for 2 weeks and once a week for seven weeks. SN to perform every home visit temperature, heart rate, blood pressure levels; with accurate documentation, patients caregiver is competent taking vital signs; scale pain 0-10, implement pain relief measures and its effectiveness; assess/monitor for medication effectiveness, possible adverse effects, duplication. SN to continue to report to Medical Doctor (MD) any changes or unfavorable response/reactions to treatments or interventions, medication adverse effects and hospitalization. During a review of P2's medications currently taking reconciling with the medication profile on 6/30/23, at 10:30 a.m., indicated the following medications were not updated in the medication profile: 1. Vascepa 1 gram 2 tablets 2x daily as supplement 2. Advair diskus 250mcg/50mcg 2 puffs daily for difficulty breathing. P2 stated was discontinued 3 months ago but was still present in medication profile. There was no DC on patient medication list. 3. Hydralazine 25 mg 1 tablet 4 times daily as needed for systolic blood pressure of 140 mmhg (millimeters of mercury- unit of blood pressure measurement). On medication profile it was recorded as twice daily. During a concurrent interview with LVN 1 on the same date and time, LVN 1 stated that she visits alternately with another LVN. LVN 1 also stated she checks the medications every home visit. LVN 1 stated that she is not sure if P1 had an order of nitroglycerin but she knows that P1 takes it regularly when she has chest pain. During a phone interview with the Doctor's Clinic on 6/30/23 at 2:20 p.m., Clinic person (CP) stated that they have to confirm the current medications to the patients pharmacy first. CP stated that on their current medication list, P1 does not have nitroglycerine ordered. During a phone interview with P1's pharmacy on 6/30/23 at 2:25 p.m., Pharmacist stated that P1 had a history of taking nitroglycerine back in 2017 under a cardiologist (a medical doctor for the heart). Pharmacist also confirmed that P1 does not have nitroglycerine on her current list of medications. During an interview with the Field Nurse Supervisor (FNS) on 6/30/23 at 3:00 p.m., FNS stated that SN has to check the medications every visit and compare with the list and put the date on the med profile whether its discontinued or continued. FNS also stated the field staff should report over the phone and the agency has to document it. FNS stated the office has to then verify and call MD about the new medication. FNS stated that the agency should document everything especially medications of the patients. FNS stated that if the medication is not on the list and the patient is taking it without a physician’s order for the medication, it is considered as a medication error and there should be an incident report, call the MD responsible for the order and add it on the current medication list. A review of the HHA's policy titled " Medication Profile" stated that patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. Visiting personnel will do medication reconciliation every visit. This reconciliation is done to avoid medication errors such as omissions, duplications, or dosing errors. Deviations in taking medications as ordered will be documented in clinical notes and the physician will be notified.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to coordinate care and services of all physicians to meet the need of one of seven sampled patients ( Patient 1). This deficient practice resulted in the omission of the nitroglycerine (a medication for chest pain) medication from the medication list and had the potential to result in the risk of severe reactions or harm to Patient 1. A review of Patient 1's (P1) Patient Profile Information indicated, a start of care (SOC) date of 3/29/23, with a certification period of 5/28/23 to 7/26/23. Patient 1's diagnosis included heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time), a history of two coronary stents (a coronary stent is a tube-shaped device placed in the coronary arteries that supply blood to the heart, to keep the arteries open in the treatment of coronary heart disease) and two episodes of stroke (occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients) and anxiety disorder (Intense, excessive, and persistent worry and fear about everyday situations. Fast heart rate, rapid breathing, sweating, and feeling tired may occur). The profile indicated the Skilled nurse (SN)visits twice a week for two weeks and once a week for seven weeks. SN to perform every home visit temperature, heart rate, blood pressure levels; with accurate documentation, patients caregiver is competent taking vital signs; scale pain 0-10, implement pain relief measures and its effectiveness; assess/monitor for medication effectiveness, possible adverse effects, duplication. SN to continue to report to Medical Doctor (MD) any changes or unfavorable response/reactions to treatments or interventions, medication adverse effects and hospitalization. A home visit was conducted on 6/30/23 at 10:15 a.m., with Licensed Vocational Nurse 1(LVN 1). Patient 1 and 2 are husband and wife. Patient 1 and Patient 2 were observed sitting in the living room area, both were alert and oriented to name, place, and time, in no respiratory distress, and walked around with a cane. Both Patient 1 and Patient 2 had periods of restlessness and anxiety. During a review of Patient 1's current medications during reconciliation Patient 1 was observed and developed anxiety. Patient 1 stood up and grabbed a small bottle in the kitchen counter and popped 1 white pill in her mouth. When asked what the bottle was, Patient 1 stated it was nitroglycerin. Patient 1 stated she was experiencing mild chest palpitations and taking nitroglycerin helps her reduce her anxiety. A review of P1's current medications reconciled with the medication profile on 6/30/23, at 10:30 a.m., indicated the following medications were not updated in the medication profile: 1. Advair 250 mcg/50 mcg (micrograms a unit of measurement) two puffs as needed for SOB was not on the list. 2. Nitroglycerin Sublingual (0.4 mg (milligram -a unit of measurement) one tablet as needed for chest pain was not listed on the medication profile. 3. Emergen-C 1000 mg one packet daily as supplement was also not listed on the medication profile. During a phone interview with the Doctor's Clinic on 6/30/23 at 2:20 p.m., Clinic person (CP) stated they have to confirm the current medications with the patients pharmacy first. CP stated according to their current medication list, nitroglycerine was not ordered for Patient 1. During a phone interview with Patient 1's pharmacy on 6/30/23 at 2:25 p.m., the Pharmacist stated Patient 1 had a history of taking nitroglycerine back in 2017 while under the care of her cardiologist (a medical doctor for the heart). Pharmacist also confirmed that Patient 1 does not have nitroglycerine on her current list of medications. During an interview with the Field Nurse Supervisor (FNS) on 6/30/23 at 3 p.m., FNS stated the SN has to check medications every visit and compare the medication with the list and enter the date on the med profile whether the medication was discontinued or continued. FNS also stated the field staff should report this over the phone and the agency is required to document it. FNS stated the office has to then verify and call the MD about the new medication. FNS stated that the agency should document everything, especially the patients medications. FNS stated if the medication is not on the list and the patient is taking it without a physician’s order, it is considered a medication error and an incident report should be completed and the nurse should call the responsible MD for an order and add it to the current medication list. A review of the HHA's policy titled " Medication Profile" stated that patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. Visiting personnel will do medication reconciliation every visit. This reconciliation is done to avoid medication errors such as omissions, duplications, or dosing errors. Deviations in taking medications as ordered will be documented in clinical notes and the physician will be notified.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure visits were conducted for one of 7 sampled patients (Patient 4) . This deficient practice resulted in the patient not receiving the required visit and resulted in a lack of care. A review of Patient 4's face sheet indicated he was admitted to the Home Health Agency (HHA) on 4/2/23, with admitting diagnosis of atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the atrial chambers of the heart). A review of patient 4’s plan of care summary indicated the skilled nurse was to visit one time a week (1x/wk). A review of the agency’s document entitled “Clinical Note” with a date of 5/1/23 indicated this was the last SN visit until 5-22-23. On 6/30/23 at 10:05 a.m. an interview was conducted with the DPCS designee in the agency office. DPCS designee verified that visits were missed for Patient 4 and stated its important to maintain a consistent home visit schedule to provide the patient with care that was ordered by the physician. On 6/30/23 a review of the agency’s undated, policy entitled “Listing of services provided” indicated that all visits must be documented and submitted to the agency, physician and the supervisor must be notified regarding each missed visit including the reason for a missed visit.

Program activities CFR(s): 484.65(c) Standard: Program activities. The HHA's performance improvement activities must-- This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to maintain an effective, ongoing, data-driven quality assessment and performance improvement program (QAPI). This deficient practice had the potential to result in a lack in improving patient safety and increase risks of transmissions of infections. On 6/30/23, the HHA’s QAPI binder was reviewed. There was a document titled “Performance Improvement Tasks 2023”, the document indicated that the agency established the following QAPI projects for 2023: 1. Fall Prevention 2. Hand Hygiene compliance 3. No Covid-19 cross contamination. The document indicated that the agency perform quarterly data collection and review for the performance improvement projects. There were no other documents in the binder. There was no evidence there was any data collected or that any quarterly reviews were being done. During an interview on 6/30/23, at 1:56 p.m., the Registered Nurse Supervisor (RNS) stated she could not find any evidence that any QAPI meetings were conducted. RNS stated the meetings should be conducted quarterly and the purpose of the QAPI program is performance improvement to review infection control, review patient records and look at patient safety. A review of The HHA’s (undated) policy titled “Performance Improvement Mechanism”, indicated the purpose to establish a performance improvement framework which integrates activities to improve organization performance, improve patient safety, and reduce the risks for acquisition and transmission of infections. The HHA is responsible for creating and maintaining information systems and data management processes to support collecting, managing, and analyzing data to improve performance. A review of the HHA’s Minutes of the Governing Body Meeting, dated 12/18/23, indicated the governing body (employees of the HHA that will assume responsibility for the operation of the HHA) is responsible for approving quarterly review of the agency’s QAPI program.

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 home health agency (HHA) failed to follow professional standards of practice for infection control by failing to failed to maintain and monitor expiry dates of their medical supplies in the office. This failure had the potential to result in the spread of infection and cause serious harm, injury or death when expired medical supplies are sent for patient use. During an agency tour on 6/29/23 at 2:00 p.m., with the office personnel (OP) and the field nurse supervisor (FNS), the following expired supplies were observed in the storage/supply room: 1. 3M Tegaderm film which had an expiration date of 6/22. 2. Xeroform occlusive Gauze patch had an expired dated of 10/31/22. 3. Curity Gauze 4X4 sponges which had expired on 4/23. 4. Abdominal pads had no expiry dates. 5. Calmoseptine cream had no expiry dates logged During a concurrent interview with OP, on the same date and time, OP stated these are the supplies given to the nursing staff when they are needed. OP also stated she was not able to arrange and monitor the supplies and confirmed there was no supply log completed since they moved to the new office. A review of the HHA's policy "Supply Maintenance" indicated "all medical supplies, especially sterile items, will be stored in a clean, dry area and handled in a sanitary manner protected from potential contamination"... "Supply packaging will remain intact while stored. If outer package is damaged or opened, supply will be removed and discarded"... "Supplies will be checked for expiration date prior to use. If outdated, the supplies will be immediately removed from stock and discarded"... "Supplies issued to a patient will not be returned from the patient's home."

Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide's performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to maintain training for their certified home health aide (CHHA) staff. This failure had the potential to result in the provision of substandard care for their patients. A review of the agency’s CHAA job description indicated competency should be demonstrated in any task to be performed listed under the CHHA duties. A review of the agency’s document entitled “Nursing Field Visit Competency Evaluation” dated and signed on 10/31/21 indicated the agency’s CHHA was evaluated on this date. No further documentation of training or in-service could be provided. On 6/30/23 at 2:15 p.m. an interview was conducted with the DPCS designee in the agency’s office. DPCS designee stated competency for CHHA should be done at least annually and the last competency was done in 2021. When asked why is it important to have regular training, DPCS designee stated to be proficient with all training. DPCS designee stated this was not done and it should have been. A review of the agency’s undated policy entitled “Personnel development” indicated the agency will provide for home health staff development and improved staff competence including, but not limited to, continuing education, in-services, seminars and training session, one to one mentoring, and continuing education. The agency requires each home health personnel to complete a minimum of the following programs each year. These must include certified home health aides who will attend 12 hours of in-service education annually. A review of the agency’s policy entitled “Personnel records” indicated the content of the personnel files for regular or part time personnel will include in-service education documentation (CHHA).

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 observation and interview, the Home health Agency (HHA) failed to ensure and safeguard Protected Health Information (PHI) against loss or unauthorized use, when the agency’s storage room was shared with another home health agency. This failure had the likelihood to result in unauthorized use or loss of patients protected health information that would create confidentiality/protection concerns with patient records. During an agency tour on 6/29/23 at 2:00 p.m., with the office personnel (OP) and the field nurse supervisor (FNS) of the supply/storage room located down the hall. OP confirmed that the storage room is for their agency only. During observation of their storage/supply room, their were multiple boxes piled on the floor and on top of each other. These were patient health records from another home health agency. Upon concurrent interview with the OP, on the same date and time, OP confirmed that the boxes are from another home health adjacent to their office. During an interview with the Field Nurse Supervisor (FNS) on 6/30/23 at 3 p.m., FNS stated the agency is not protecting patient health information if the storage area is unlocked and another agency can go inside the storage room. A review of the HHA's policy dated and revised 3/2018, titled " Patient Confidentiality" indicated all written patient information is stored in the patient's medical record. Charts are not to be removed from the office unless a specific reason has been identified and approved. Home care records will not be left in an unattended area in the office. Files will be protected against unauthorized corruption, damage and/or intrusion. Persons who are not employees of the agency should not have access to the office after normal business hours, such as cleaning services. However, all home records will be kept stored in metal file cabinets or locked file room after to decrease the likelihood of accessibility by such persons.