Every finding on record at Excellence Home Healthcare LLC

Substantial Allegation Survey Substantial Allegation 71731 An entrance conference was conducted with administrative staff on 09/07/22, and an exit conference was conducted on 09/07/22. The following deficiencies are based upon substantial allegation 71731 completed on 09/07/22. Excellence Home Healthcare LLC 369014, is not in compliance with the requirements at 42 CFR Part 484, Subpart B,C for Home Health Agencies.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure the home health aide provided services included in the plan of care for one of three patients reviewed (Patient #1). This could affect all patients receiving services from the agency. The agency census was 31. Findings include: Review of the medical record for Patient #1 for the certification periods dated 05/23/22 through 07/21/22 and 07/22/22 through 09/19/22 revealed the physician orders included skilled nursing services once weekly and home health aide services daily. The home health aide orders and frequency included four hours daily to assist with personal care needs, light housekeeping, and activities of daily living. Per the home health aide plan of care the aide was to assist with personal care that included bathing, grooming, dressing with each visit and to assist with laundry once weekly and as needed. Review of the home health aide time sheets from 05/23/22 to 08/28/22 revealed home health aide services was provided daily; however, there was no documentation assistance was provided with showering and/or dressing. This finding was confirmed with Staff C on 09/07/22 at 2:32 PM. This deficiency substantiates Substantial Allegation 71731.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on record review, staff interview, and policy review, the agency failed to ensure clinical notes were maintained in the medical record for one of three patients reviewed (Patient #3). This could affect all patients receiving services from the agency. The agency census was 31. Findings include: Review of the undated facility policy titled, "Home Health Aide Documentation," revealed the agency will ensure accurate documentation of home health aide services. The home health aide will document services rendered to the patient on the appropriate home health aide charting form as directed in the aide care plan/assignment sheet. Review of the medical record for Patient #3 for the certification period dated 06/05/22 through 08/03/22 revealed physican orders for home health aide services twice daily to assist with personal care. The medical record lacked home health aide visit notes for the entire certification period. Review of electronic visit verification (EVV) records revealed the home health aide was present in the home, but the EVV records did not provide details of what care was provided. On 09/07/22 at 4:33 PM Staff B confirmed in an interview that the home health aide visits were provided according to the schedule; however, home health aide clinical notes were not turned in as per policy.

Substantial Allegation Survey Substantial Allegation 62980 An entrance conference was conducted on 05/24/22 at 9:45 AM with administrative personnel, and an exit conference was completed on 05/24/22 at 5:00 PM with administrative personnel. No deficiencies were cited related to allegation(s) contained in substantial allegation 62980 completed on 05/24/22; however, the facility was found not to be in compliance with all requirements for Home Health Agency participation and the following deficiency is cited. Excellence Home Healthcare LLC 369014, is not in compliance with the requirements found at 42 CFR Part 484 Subpart B, C for Home Health Agencies.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure coordination of care by all disciplines was documented for one of three medical records reviewed (Patient #1). The agency census was 32. Findings include: Review of the medical record for Patient #1 revealed an emergent admission to the hospital on 02/19/22. The medical record contained a Transfer Outcome Assessment and Information Set (OASIS) form dated 02/19/22 that stated the patient reportedly was vomiting and could not hold down food or fluids and the aide was notified to call 911. The medical record lacked documentation of the time the aide was notified to call 911 or the time the aide called 911. The home health aide note lacked documentation of any issue, calling the nurse or 911, or the time the patient left by ambulance. The medical record lacked documentation of any of the conversations with the aide and any of the nurses on 02/19/22. On 05/24/22 at 1:10 PM, Staff B was interviewed. Staff B stated he/she called the nurse to provide an update on the patient's condition and was instructed to call 911. Staff B stayed with the patient until he/she left by ambulance. On 05/24/22 at 1:37 PM, Staff D stated he/she was on the way to Patient #1's home for the morning visit when he/she received a call regarding the patient's condition. Staff D spoke to the patient's family member regarding Patient #1's condition and directed them to call 911 and go to the hospital for evaluation. Staff D stated he/she did not document this phone call but notified the office. On 05/24/22 at 4:51 PM, Staff A stated that he/she completed the Transfer OASIS form. Staff A verified that the conversations with the home health aide, the nurse, and the patient's family were not documented and the exact times of these conversations were not recorded.

Extended Substantial Allegation Survey Substantial Allegation 62211 An entrance conference was conducted on 04/12/22 at 12:55 PM with administrative personnel, and an exit conference was completed on 04/13/22 at 3:50 PM with administrative personnel. The following deficiencies are based on the substantial allegation survey completed on 04/13/22. Excellence Home Healthcare LLC 369014, is not in compliance with the requirements found at 42 CFR Part 484 Subpart B, C for Home Health Agencies. Excellence Home Healthcare LLC is precluded from offering its own aide training and/or competency evaluation program for a period of two years from the exit date of this survey.

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 review of QSO memo 22-09-ALL Attachment G, review of facility COVID-19 vaccination records, review of facility policy and procedure and staff interview, the home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. The cumulative effect of these systemic practices resulted in the agency's inability to ensure that the patients' infection control needs would be met. G687

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on review of QSO memo 22-09-ALL Attachment G, policy review, staff vaccination record review and staff interview, the agency had a vaccination rate of 95.5% and failed to ensure medical exemptions from vaccination have been signed and dated by a licensed practitioner who is not the individual requesting the exemption, specify why the vaccine is clinically contraindicated, and contain the statement by the authenticating practitioner recommending the staff member be exempted from the vaccine requirements based on the recognized clinical contraindications for two of 44 staff (Staff D and E). The census was 32 patients. Findings include: Review of QSO memo 22-09-ALL Attachment G revealed that within 60 days following the issuance of the applicable memorandum policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or resident contact are vaccinated for COVID-19, including all required components of the policies and procedures 100% of staff have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple vaccine series) or have been granted a qualifying exemption, or are identified as having a temporary delay as recommended by the Centers for Disease Control (CDC). Review of the "Covid-19 Vaccination Exemption Policy", approved 01/10/22, revealed a medical exemption must be determined to be contraindicated for an individual, must have a documented statement by the authenticating practitioner recommending the individual be exempted from the requirement to be fully vaccinated based on the recognized clinical contraindications, and the statement must be signed and dated by a licensed practitioner who is not the individual requesting the exemption. Review of the vaccination information for Staff E revealed she had received the first dose of a two dose vaccination series on 09/07/21. Interview with Staff A on 04/12/22 at 3:15 PM revealed Staff E was partially vaccinated due to becoming pregnant. There was no evidence of a medical exemption request for Staff E. Review of the medical exemption for Staff D revealed one sentence stating the reason not vaccinated and was signed by Staff D, but not dated. The document lacked the statement from a licensed practitioner, the clinical contraindications to being vaccinated, or a signature and date by the licensed practitioner. Interview with Staff D on 04/12/22 at 4:02 PM revealed she planned to get vaccinated after having the baby due to being a high risk pregnancy. The findings were verified in an interview with Staff A on 04/13/22 at 3:35 PM. This deficiency substantiates Substantial Allegation 62211.