Every finding on record at Everest Home Health & Hospice, LLC

After concerns were identified at the home health’s sister-agency (a hospice), which also affected the home health agency (HHA), a complaint/abbreviated survey was then conducted at Everest Home Health from 2/1/2024 through 2/8/2024. Based on interview and record review, it was determined that the HHA failed to implement and govern a home health emergency preparedness program according to Medicare’s Conditions for Participation for home health agencies. Noncompliance was identified in the following area: §484.102 Emergency preparedness

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.542, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must establish and maintain a [comprehensive] emergency preparedness program that meets the requirements of this section.* The emergency preparedness program must include, but not be limited to, the following elements: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on interview, it was determined the home health agency (HHA) failed to implement, maintain, and document a current emergency preparedness (EP) program. Specifically, there was no governing body or appointed administrator in place that implemented and maintained an EP program that included an EP plan, communication plan, risk assessment, policy and procedures, staff training, and testing of the emergency plan. Findings include: 1. The HHA failed to provide evidence, by interview or documentation, that they had maintained an EP program that included EP plan, communication plan, risk assessment, policy and procedures, staff training, and testing of the emergency plan. Therefore none of the standards (tags: E0004, E0006, E0007, E0009, E0013, E0017, E0019, E0021, E0023, E0024, E0029 through E0034, E0036, E0037, E0039, E0042) under this condition (tag: E0001) could be met. 2. On 2/1/2024, the following was requested from the director of nursing (DON): a. Emergency preparedness plan and risk assessments b. Emergency preparedness policy and procedures c. Emergency preparedness communication plan d. Documentation of emergency preparedness training of staff e. Documentation of annual emergency preparedness exercises conducted 3. In an interview with the DON on 2/5/2024, at 2:52 PM, the DON stated she was unable to provide current documentation of a formal emergency preparedness program.

After concerns were identified at the home health’s sister-agency (a hospice), which also affected the home health agency (HHA), a complaint/abbreviated survey was then conducted at Everest Home Health from 2/1/2024 through 2/8/2024. Based on interview and record review, it was determined that the HHA failed to implement and govern a home health program according to Medicare’s Conditions for Participation for home health agencies. Noncompliance was identified in the following areas: §484.55 Comprehensive assessment of patients, §484.65 Quality assessment and performance improvement, §484.70 Infection control, §484.102 Emergency preparedness, §484.105 Organization and administration of services, and, §484.110 Clinical records. The complaint was substantiated and deficiencies were cited. Additionally, on 2/8/2024, a finding of Immediate Jeopardy (IJ) (immediate threat to the health and safety of patients) was identified. The home health agency was notified of this finding verbally and in writing on 2/8/2024 at 12:10 PM. The survey team exited the survey on 2/8/2024. During the immediate jeopardy situation, surveyors continued to monitor the agency’s activities. On 2/12/2024, the administrator, who was also the director of nursing, the only staff nurse, the office staff, the on-call 24/7 nurse, and the aide resigned. All patients had been discharged, and the IJ situation was abated. However, the home health agency was unable to care for patients because they had no staff or functioning operation and remained in substantial non-compliance. On 2/27/2024 at 11:34 PM, the state agency received notification from the named governing body they were being shut down by the tax commission due to unpaid payroll taxes from previous years. On 2/28/2024 at 9:07 AM, the state agency attempted contacting the owner/administrator of record to apprise them of the situation, there was no answer and the voice mailbox was full so no message could be left. On the morning of 2/28/2024, the owner/administrator/emergency contact of record were informed by the state agency via email. Note: the owner of record stated the agency had been sold and she was no longer a part of the agency and refused to participate in the survey process. She directed surveyors to speak with the alleged new owners. The alleged new owners stated the sale of the agency had not been finalized, but agreed they would be the contact person during the survey.

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 interview and medical record review, it was determined the home health agency (HHA) did not ensure that all patient medications had been reviewed as part of the comprehensive assessment and updated on the patients' medication profile for 1 of 5 sampled patients. (Patient identifier: 1) Findings include: Patient 1 was admitted on 12/22/2023, with a diagnosis of Hematemesis. On 2/8/2024, a review of patient 1's medical record was completed. Patient 1’s plan of care listed medications as “none”. Documented evidence showed on a nurse’s note dated 1/4/2024, the patient had seen her primary care physician (PCP) on 12/30/2023, and it was recommended to discontinue spironolactone. Documented evidence further showed on a physical therapy assistant (PTA) visit note “vital sign alert” blood pressure reading of 151/60. Comment stated, "family stated she has not had her blood pressure medication." On 2/5/2024 at 1:48 PM, an email was sent to the director of nursing (DON) requesting information on patient 1’s medications. On 2/5/2024 at 1:55 PM, an email was received from the DON stating that the physical therapist was the case manager and the admitting personnel for patient 1. The DON further stated she would communicate to the physical therapist that no medication had been added to the chart. No further information was received by surveyors from the DON. During a home visit on 2/7/2024 at 11:00 am, the surveyor obtained a list of patient 1’s current medications: Omeprazole 20 mg once daily Atorvastatin 20 mg once daily Amlodipine 10 mg once daily Furosemide 20 mg once daily Famotidine 20 mg once daily Fluoxetine 20 mg once daily Alendronate 70 mg every Wednesday These medications and doses were confirmed with the patient and daughter at the home visit. Surveyor was told by the daughter of the patient that the initial assessment was completed by the physical therapist.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on interview, it was determined the home health agency (HHA) failed to implement, maintain, and document a home health-wide data-driven quality assessment and performance improvement (QAPI) program. Specifically, there was no governing body or appointed administrator in place that implemented and maintained a QAPI program. Findings include: 1. The HHA failed to provide evidence, by interview or documentation, that they had developed, implemented, evaluated, and maintained an effective, ongoing, HHA-wide data-driven QAPI program which reflected the complexity of its organization and services. They could provide no evidence of current data collection, monitoring, tracking, measuring, or analyzing to determine problem-prone high-risk areas for improvement in patient safety and quality of care. Therefore none of the standards (tags: G642 through G660) under this condition (tag: G640) were met. In an interview with the director of nursing (DON) on 2/5/2024, at 2:52 PM, the DON stated she was unable to provide current documentation of a formal QAPI program. She stated the previous administrator was over the program and currently there was no administrator or governing body to maintain the QAPI program.

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on interview, it was determined the home health agency (HHA) failed to implement, maintain and document an infection prevention and control program. Specifically, there was no governing body or appointed administrator in place that implemented and maintained an infection control program. Findings include: 1. The HHA failed to provide evidence, by interview or documentation they had implemented and maintained a coordinated agency-wide program for surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. Therefore none of the standards (tags: G682, G684, and G686) under this condition (tag: G680) were met. In an interview with the DON on 2/5/2024, at 2:52 PM, the DON stated she was unable to provide current documentation of a formal infection program. She stated the previous administrator was over that program and currently there was no administrator or governing body to maintain the infection control program.

Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient's plan of care, for each patient's medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This CONDITION is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) failed to meet the requirements for organization and administration of services. Specifically, the HHA failed to assume full legal authority and responsibility for the management of the home health agency. They failed to have a functioning governing body (GB) that implemented and maintained a quality assurance performance improvement (QAPI), infection control, and emergency preparedness (EP) programs; have an administrator and pre-designated administrator that was appointed by the GB; have performed institutional planning under the direction of the GB; and have maintained clinical records in accordance with acceptable standards of practice. Findings include: 1. The HHA failed to ensure all patient medications had been reviewed as part of the comprehensive assessment and updated on the patients' medication profile. (Refer to tag G536) 2. The HHA failed to implement, evaluate, and maintain an effective, ongoing, QAPI program which reflected the complexity of its organization and services. (Refer to tag G640) 3. The HHA failed to implement and maintain a coordinated agency-wide program for surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. (Refer to tag G680) 4. The HHA failed to have a functioning governing body that assumed full legal authority and responsibility for the HHA's overall management and operations. This resulted in a finding of immediate threat to patient health and safety (Immediate Jeopardy) (IJ), on 2/8/2024. 5. The HHA failed to ensure the agency administrator was appointed by and could report to the governing body. (Refer to tag G946) 6. The HHA failed to notify the state survey agency that their approved branches were no longer active and functioning. (Refer to tag G972) 7. The HHA failed to have an overall financial plan and budget that was prepared, reviewed and updated annually under the direction of the governing body. (Refer to tag G988) 8. The HHA failed to provide unrestricted access of the electronic medical records to the director of nursing and the person verbally named as the administrator during the survey. (Refer to tag G1008) 9. The HHA failed to establish and maintain a current EP program that included an EP plan, communication plan, risk assessment, policies and procedures, staff training, and testing of the emergency plan. (Refer to tag E0001)

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on interview and document review, it was determined the home health agency (HHA) did not ensure there was a governing body, that assumed full legal authority and responsibility for the management of the home health, the provision of all home health services, and its fiscal operations. Specifically, the home health did not ensure there was a qualified administrator appointed by and reporting to the governing body was responsible for the day-to-day operation of the home health; there was an appointed person to assume the administrator’s responsibilities in the absence of the administrator; and there was an overall financial plan and budget that was prepared, reviewed and updated under the direction of the governing body. On 2/8/2024, a finding of Immediate Jeopardy (IJ) (immediate threat to the health and safety of patients) was identified. The HHA was notified of this finding verbally and in writing on 2/8/2024 at 12:10 PM. The survey team exited the survey on 2/8/2024. During the immediate jeopardy situation, surveyors continued to monitor the agency’s activities. On 2/12/2024, the administrator, who was also the director of nursing, the only staff nurse, the office staff, and the aide resigned. Along with her, the social worker resigned. All patients had been discharged, and the IJ situation was abated. However, the home health agency was unable to care for patients because they had no staff or functioning operation and remained in substantial non-compliance. On 2/27/2024 at 11:34 PM, the state agency received notification from the named governing body they were being shut down by the tax commission due to unpaid payroll taxes from previous years. On 2/28/2024 at 9:07 AM, the state agency attempted contacting the owner/administrator of record to apprise them of the situation, there was no answer and the voice mailbox was full so no message could be left. On the morning of 2/28/2024, the medical director and owner/administrator/emergency contact of record were informed by the state agency via email. Findings include: 1. Prior to the start of the survey, the HHA could not provide evidence, by interview or documentation, they had a governing body in place that had appointed an administrator who was responsible for the day-to-day operation of the HHA. During the entrance interview, the director of nursing (DON) stated there was no current named administrator that had been communicated to her. The DON stated the current owner/administrator was no longer involved and the HHA did not have a governing body or administrator. She stated the staff had quit due to not being paid, the aides were refusing to see patients until they were paid, and that payroll had not been fulfilled for January 2024. 2. The HHA could not provide evidence, by interview or documentation, that they had a qualified pre-designated person to assume the same responsibilities and obligations as the administrator in the event of the administrator's absence. During the entrance interview, the DON stated no backup administrator had been appointed. 3. The HHA could not provide evidence, by interview or documentation, that the HHA assumed full legal authority and responsibility for the management of the HHA, and its fiscal operations, or that an overall financial plan and budget was prepared, reviewed and updated under the direction of a governing body. During the entrance interview, the DON stated the staff had quit due to not being paid, the aides were refusing to see patients until they were paid, and the payroll had not been fulfilled for January 2024. (see interview above) In an interview with the Physical Therapist (PT) on 1/31/2024 at 10:53 AM, he stated “I was paid for November but it was late, not until December 20, (2023). As of now, I have not received any pay for December.” In an Interview with the DON on 1/31/2024 at 10:20 AM, she stated that she had postponed her pay so the aides could get paid for December. As of the end of the survey, no staff had been paid for January 2024. 4. The HHA could not provide evidence, by interview or documentation, that they had maintained an organizational structure with a functioning governing body to oversee the HHA’s functions and programs. On 2/5/2024, the following was requested from the director of nursing (DON): a. Governing Body Meeting Minutes b. Documentation of the HHA’s overall organizational structure and an organizational chart c. The HHA’s budget d. Policies and Procedures e. Quality Assessment and Performance Improvement (QAPI) Meeting Minutes In an interview with the DON on 2/5/2024, at 2:52 PM, the DON stated she was unable to provide the listed items. She stated she did not have the resources to act as the functioning administrator who had all rights and authority to direct day-to-day agency functions, or the capability to do so because the agency was in limbo. The DON stated that since the owner/administrator ceased to be involved, she was unaware of who the governing body was and that there had not been governing body meetings or QAPI meetings. She further stated that since the resignation of the office manager, she had limited access to the electronic medical record which limited her ability to document as needed or update patient care plans. The DON further stated she was unable to provide current documentation of a budget. The DON also stated the policies available for the agency had not been updated since 2011.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on interview and document review, it was determined the home health agency (HHA) did not have an agency administrator who was appointed by and could report to the governing body and who was responsible for all day-to-day operations of the HHA. Specifically, the agency had no appointed administrator. Additionally, the governing body was not communicating with the director of nursing (DON) who was verbally named the administrator during the survey. Findings include: The HHA could not provide evidence, by interview or documentation, that they had appointed an agency administrator who could report to the governing body and who was responsible for all day-to-day operations of the HHA. In an interview with the DON on 2/5/2024 at 2:52 PM, the DON stated she was working for both the home health agency and their sister-agency (a hospice) as the sole nurse functioning as a visit nurse, DON, aide, on-call 24/7 for the sister-agency, and had been verbally named the administrator during the survey. The DON/administrator was asked if she felt she could perform all the duties requested of her and she stated, “I cannot”. Due to the agency still being in an immediate jeopardy situation at the time of exit, the agency was continually monitored by the state agency. During the monitoring, the following occurred: after exit on 2/12/2024 at 10:40 AM, surveyors were notified by email that the DON/administrator had resigned from the agency after transferring the remaining 2 patients.

Report all branch locations to SA CFR(s): 484.105(d)(1) The parent HHA is responsible for reporting all branch locations of the HHA to the state survey agency at the time of the HHA's request for initial certification, at each survey, and at the time the parent proposes to add or delete a branch. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined the home health agency (HHA) did not notify the state survey agency that their approved branches were no longer active and functioning. Findings include: The state system showed additional branches listed as open in Vernal and Roosevelt. On 2/1/2024 at 9:10 AM, during entrance with the director of nursing when asked about their branch locations, she stated that she did not know of any other locations. Documented evidence showed that in governing body meeting minutes dated 11/28/2023 at 10:00 AM, “Growth opportunity in Vernal/Roosevelt is high due to (health insurance company) approving the (national health insurance) opportunity for billing.” The minutes were signed by the administrator and emergency contact on file listed in the state system. No documented evidence was found that the HHA had notified the state survey agency that the additional branches were no longer active and functioning.

Institutional planning CFR(s): 484.105(h) Standard: Institutional planning. The HHA, under the direction of the governing body, prepares an overall plan and a budget that includes an annual operating budget and capital expenditure plan. (1) Annual operating budget. There is an annual operating budget that includes all anticipated income and expenses related to items that would, under generally accepted accounting principles, be considered income and expense items. However, it is not required that there be prepared, in connection with any budget, an item by item identification of the components of each type of anticipated income or expense. (2) Capital expenditure plan. (i) There is a capital expenditure plan for at least a 3-year period, including the operating budget year. The plan includes and identifies in detail the anticipated sources of financing for, and the objectives of, each anticipated expenditure of more than $600,000 for items that would under generally accepted accounting principles, be considered capital items. In determining if a single capital expenditure exceeds $600,000, the cost of studies, surveys, designs, plans, working drawings, specifications, and other activities essential to the acquisition, improvement, modernization, expansion, or replacement of land, plant, building, and equipment are included. Expenditures directly or indirectly related to capital expenditures, such as grading, paving, broker commissions, taxes assessed during the construction period, and costs involved in demolishing or razing structures on land are also included. Transactions that are separated in time, but are components of an overall plan or patient care objective, are viewed in their entirety without regard to their timing. Other costs related to capital expenditures include title fees, permit and license fees, broker commissions, architect, legal, accounting, and appraisal fees; interest, finance, or carrying charges on bonds, notes and other costs incurred for borrowing funds. (ii) If the anticipated source of financing is, in any part, the anticipated payment from title V (Maternal and Child Health Services Block Grant) or title XVIII (Medicare) or title XIX (Medicaid) of the Social Security Act, the plan specifies the following: (A) Whether the proposed capital expenditure is required to conform, or is likely to be required to conform, to current standards, criteria, or plans developed in accordance with the Public Health Service Act or the Mental Retardation Facilities and Community Mental Health Centers Construction Act of 1963. (B) Whether a capital expenditure proposal has been submitted to the designated planning agency for approval in accordance with section 1122 of the Act (42 U.S.C. 1320a-1) and implementing regulations. (C) Whether the designated planning agency has approved or disapproved the proposed capital expenditure if it was presented to that agency. (3) Preparation of plan and budget. The overall plan and budget is prepared under the direction of the governing body of the HHA by a committee consisting of representatives of the governing body, the administrative staff, and the medical staff (if any) of the HHA. (4) Annual review of plan and budget. The overall plan and budget is reviewed and updated at least annually by the committee referred to in paragraph (i)(3) of this section under the direction of the governing body of the HHA. This STANDARD is not met as evidenced by: Based on interview and record review, it was determined that the home health agency (HHA) did not have an overall financial plan and budget that was prepared, reviewed and updated annually under the direction of the governing body. Findings include: In an interview with the director of nursing (DON) on 2/5/2024, at 2:52 PM, the DON stated she was unable to provide current documentation of a budget. She further stated, “They (the named governing body) have never given me anything, I don’t even have a phone number to call with questions, only an email that they never respond to.” No documentation was provided during the survey process that indicated that the budget had been developed and reviewed under the direction of the governing body.

Clinical records CFR(s): 484.110 Condition of participation: Clinical records. The HHA must maintain a clinical record containing past and current information for every patient accepted by the HHA and receiving home health services. Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) or allowed practitioner(s) issuing orders for the home health plan of care, and appropriate HHA staff. This information may be maintained electronically. This CONDITION is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to maintain clinical records that were readily available and contained all the required information. Findings include: In an interview with the director of nursing (DON) on 2/5/2024, at 2:52 PM, the DON stated that since the resignation of the office manager on 1/31/2024, who was the only one with administrative access, she now had limited access to the electronic medical record (EMR), this limited her ability to document or retrieve needed information or update patient care plans. The HHA failed to provide unrestricted access of the clinical record to the DON and the person who was named as the administrator during the survey.