Every finding on record at Excell Home Health Services

This Statement of Deficiencies was generated as a result of an Emergency Preparedness survey conducted at your agency from May 17, 2022 through May 20, 2022, in accordance with 42 Code of Federal Regulations (CFR) and the State Operations Manual (SOM), Appendix Z- Emergency Preparedness for All Provider and Certified Supplier Types. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigations, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following deficiencies were identified:

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures at least every 2 years. Findings include: On 05/20/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated all its policies and procedures at least every 2 years. On 05/20/2022 in the afternoon, the Administrator confirmed not all the policies and procedures were reviewed at least every two years.

Homebound HHA/Hospice Inform EP Officials CFR(s): 484.102(b)(2) §418.113(b)(2), §460.84(b)(4), §484.102(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] *[For homebound Hospice at §418.113(b)(2), PACE at §460.84(b)(4), and HHAs at §484.102(b)(2):] The procedures to inform State and local emergency preparedness officials about [homebound Hospice, PACE or HHA] patients in need of evacuation from their residences at any time due to an emergency situation based on the patient's medical and psychiatric condition and home environment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to identifying patients in need of home evacuation at least every 2 years. Findings include: On 05/06/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated all its policies and procedures regarding identifying patients needing evacuation from their residences at least every 2 years. On 05/20/2022 in the afternoon, the Administrator confirmed not all the policies and procedures were reviewed at least every two years.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to identifying on duty staff or patients the agency was unable to contact at least every 2 years. Findings Include: On 05/06/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding identifying on duty staff or patients the agency was unable to contact and report to state and local officials at least every 2 years. On 05/20/2022 in the afternoon, the Administrator confirmed not all the policies and procedures were reviewed at least every two years.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility's] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility's] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI's care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility's care as permitted under 45 CFR 164.510(b)(4). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure it reviewed and updated its emergency preparedness policies and procedures related to its communication plan at least every 2 years. Findings include: On 05/20/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding its communication plan at least every 2 years; specifically to include all of the following: A method for sharing information and medical documentation for patients under the [agency's] care, as necessary, with other health providers to maintain the continuity of care, and the means for providing information about the general condition and location of patients under the [agency's] care as permitted under 45 CFR 164.510(b)(4). On 05/20/2022 in the afternoon, the Administrator confirmed not all the policies and procedures were reviewed at least every two years.

Information on Occupancy/Needs CFR(s): 484.102(c)(6) §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(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: (7) [(5) or (6)] A means of providing information about the [facility's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice's inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This STANDARD is not met as evidenced by: On 05/06/2022 in the afternoon, the agency provided numerous documents related to emergency preparedness. In conjunction with the overall emergency preparedness plan and associated documents, there was no documented evidence the agency reviewed and updated its policies and procedures regarding its communication plan at least every 2 years; specifically, to include all of the following: A means of providing information about the [agency's] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. On 05/20/2022 in the afternoon, the Administrator confirmed not all the policies and procedures were reviewed at least every two years.

This Statement of Deficiencies was generated as a result of the Medicare Recertification survey and Healthcare Worker (HCW) Vaccine Mandate conducted at your agency from May 17, 2022, through May 20, 2022, in accordance with 42 CFR (Code of Federal Regulations) Part 484 - Home Health Services. Seven clinical records were reviewed. Three home visits were conducted. The investigation of regulatory compliance for COVID-19 Vaccination of Facility Staff included: - Review of Infection Control Surveillance plans. - Review of Vaccination policies including staff members vaccination status, exemptions, (medical and non-medical), temporary delays for vaccinations, additional precautions for unvaccinated staff, contingency plans for unvaccinated staff and additional precautions to prevent the spread of Covid -19. Review of the facility's Healthcare Worker Vaccination policies and facility documentation revealed the facility was at 100% compliance with Healthcare Worker vaccination requirements. The findings and conclusions of any investigation by the Division of Public and Behavioral Health shall not be construed as prohibiting any criminal or civil investigation, actions or other claims for relief that may be available to any party under applicable federal, state, or local laws. The following regulatory deficiencies were identified:

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the facility failed to follow physician orders when cleaning an open wound for 1 of 7 sampled patients (Patient #2) Findings include: Patient #2 Patent #2's start of care was 11/25/2021, with diagnoses including diabetes, malignant neoplasm, and non-healing abdominal wound. A home visit was conducted with the Licensed Practical Nurse (LPN) on 05/18/2022 in the afternoon. The patient's plan of care (03/25/2022 - 05/23/2022) ordered to treat the abdominal wound twice a week by cleaning with normal saline, pat dry, apply Medihoney, and covering with calcium alginate dressing. On 05/18/2022 in the afternoon, the LPN treated the patient's open abdominal wound by cleaning the site with a Carraklenz wound cleanser spray and not with normal saline. There was no documented evidence an order was obtained to use Carraklenz to clean the open wound. On 05/20/2022 in the morning, the agency supply room had bottles of normal saline and Carraklenz spray bottles. On 05/20/2022 in the morning, the Registered Nurse (RN) confirmed the LPN should have followed the physician orders and used normal saline to wash the patient's open wound and not the Carraklenz spray bottle solution. The RN indicated the solutions were different.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to follow physician orders when cleaning an open wound for 1 of 7 sampled patients (Patient #2), and obtain a physician order for a feeding solution for 1 of 7 sampled patients (Patient #5). Findings include: Patient #2 Patent #2's start of care was 11/25/2021, with diagnoses including diabetes, malignant neoplasm, and non-healing abdominal wound. A home visit was conducted with the Licensed Practical Nurse (LPN) on 05/18/2022 in the afternoon. The patient's plan of care (03/25/2022 - 05/23/2022) ordered to treat the abdominal wound twice a week by cleaning with normal saline, pat dry, apply Medihoney, and covering with calcium alginate dressing. On 05/18/2022 in the afternoon, the LPN treated the patient's open abdominal wound by cleaning the site with a Carraklenz wound cleanser spray and not with normal saline. There was no documented evidence an order was obtained to use Carraklenz to clean the open wound. On 05/20/2022 in the morning, the agency supply room had bottles of normal saline and Carraklenz spray bottles. On 05/20/2022 in the morning, the Registered Nurse (RN) confirmed the LPN should have obtained a physician order to use Carraklenz to clean the patient's wound. The RN confirmed the LPN should have followed the physician orders and used normal saline to wash the patient's open wound and not the Carraklenz spray bottle solution. The RN indicated the solutions were different. Patient #5 Patient #5's start of care was 01/22/2022, with diagnoses including protein-calorie malnutrition, adult failure to thrive, and gastrostomy status. The patient's plan of care (01/22/2022 - 03/22/2022) indicated the patient was on a Dietary Approaches to Stop Hypertension (DASH) diet along with Jevity 1.5 calories/day taken orally. The patient skilled nursing notes dated 01/26/2022, 01/28/2022, and 02/03/2022 indicated the patient's special feeding instructions were to take isosource through the feeding tube. There was no documented evidence an order was obtained to have the patient start isosource feedings. On 05/20/2022 in the morning, the RN indicated a physician order should have been obtained for the isosource solution.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to assess an intravenous midline access site for 1 of 7 sampled patients (Patient #2) and failed to assess a patient weights for 1 of 7 sampled patients (Patient #5). Findings include: Patient #2 Patent #2's start of care was 11/25/2021, with diagnoses including diabetes, malignant neoplasm, and non-healing abdominal wound. A home visit was conducted with the Licensed Practical Nurse (LPN) on 05/18/2022 in the afternoon. On 05/18/2022 in the afternoon, the patient had a dressing on the left upper arm. The dressing was ¾ covered by the patient’s shirt. The LPN indicated the patient had an intravenous (IV) access to the left upper arm and indicated the Registered Nurse (RN) or family friend took care of the maintenance of the IV line. The LPN did not assess the area. On 05/19/2022 in the afternoon, the RN indicated the patient had a midline IV access line being taken care of and maintained by a friend. The RN indicated they did not assess the friend’s knowledge base to determine if the friend knew how to take care of the IV line. The RN indicated they did not confirm with the physician to determine how the IV line was supposed to be maintained. The RN indicated they did not know when the dressing was supposed to be changed or when the last time the IV lines were flushed and with what type of solutions. The RN indicated they should have assessed the area, assessed the knowledge base of the friend taking care of the midline IV line, and confirmed with the physician how the IV line was to be maintained. Patient #5 Patient #5's start of care was 01/22/2022, with diagnoses including protein-calorie malnutrition, adult failure to thrive, and gastrostomy status. The patient's plan of care (01/22/2022 - 03/22/2022) indicated the patient was on a Dietary Approaches to Stop Hypertension (DASH) diet along with Jevity 1.5 calories/day taken orally. The plan of care indicated the patient was at risk to go to the emergency room due to significant weight loss in the past 6 months. The frequency of the skilled nursing visits were one time a week for one week, two times a week for two weeks, and one time a week for six weeks. There was no documented evidence an initial weight was obtained or weights obtained during skilled nursing visits to determine if the patient was losing further weight. On 05/20/2022 in the morning, the Registered Nurse indicated the patient should have had weights assessed for every visit due to the diagnoses of malnutrition and the risk of going to the emergency room due to unintentional significant weight loss in the last 10 months.

Social Worker CFR(s): 484.115(m) Standard: Social worker. A person who has a master's or doctoral degree from a school of social work accredited by the Council on Social Work Education, and has 1 year of social work experience in a health care setting. This STANDARD is not met as evidenced by: Based on interview, record review and document review, the facility failed to confirm if their social workers were qualified for their positions for two of two Social Workers (Social Worker 1 and 2). Findings include: The agency' s undated policy titled Categories/Qualifications of Personnel documented the social worker qualifications were to have a master’s degree from a school accredited or approved by the council on Social Work Education. The State of Nevada Board of Examiners for Social Workers revealed Social Worker 1 was a Licensed Certified Social Worker, and Social Worker 2 was a Licensed Social Worker. There was no verified documented evidence Social Worker 1 and 2 were master’s degree holders from a school accredited or approved by the council on Social Work Education. On May20, 2022 in the afternoon, the Administrator indicated the agency did not verify if their social workers had a master’s degree from a school accredited or approved by the council on Social Work Education. The Administrator indicated a Bachelor degree social worker was sufficient.