Every finding on record at First Choice Home Health Care LLC

A recertification inspection survey was conducted on 10/23/2023. The licensed and certified home health services census was 27. Abbreviations/Acronyms: Adm-Administrator Alt Adm -Alternate Administrator DON-Director of Nursing EP-Emergency Preparedness

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop 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: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to comply with all applicable Federal, State and local emergency preparedness requirements, in that: the agency failed to maintain an emergency preparedness plan that was reviewed (to evaluate the plan’s effectiveness) and updated at least annually per state regulatory requirements for three (2021, 2022 and 2023) of three years reviewed. The failure could place the agency’s clients at risk of harm if the EP plan were not effective and needed updating. Findings included: During the entrance conference at 11:12 a.m. on 10/23/2023, the Alt Adm self-identified as the disaster coordinator. The Alt Adm identified the DON as the alternate disaster coordinator. The surveyor requested (all) agency emergency preparedness and response plan documents/reports/manuals. Review of the emergency preparedness and response plan binder did not reveal any completed internal reviews of the agency’s EP plan for the years 2021, 2022 and 2023. The EP binder contained the following: A document tilted, "Analysis of Risk Assessment for Potential Disasters." The "…Assessment for Potential Disasters" included potential disaster titles of Natural Disasters, Technological Hazards, Epidemic, and Terrorism. The listed disasters were not designated a “risk level.” The assessment was not completed, signed, or dated by the Alt Adm, DON, or other agency representative. The binder also contained an agency policy for emergency preparedness dated 01/13/18; an incomplete, unsigned, and undated continuity of operations business plan; documentation for activation of the agency’s EP response for weather events on 02/25/2021, 08/21/2022, and 01/30/2023; and a blank/not completed “Agency Emergency Preparedness Plan Evaluation.” The binder did not include the last completed internal review of the agency’s EP plan. During an interview with the DON on 10/25/2023 at 1:59 p.m. the surveyor asked if the agency had provided all agency’s requested records for the agency’s EP program. The DON stated, “Yes.” The surveyor asked who at the agency was responsible for the agency’s EP program. The DON stated that she and the Alt Adm were responsible for the program. During an interview with the Alt Adm on 10/26/2023 at 4:00 p.m. the surveyor asked which (01/13/18 or 07/01/23, online policy) agency policy was the current policy used by the agency. The Alt Adm stated the online policies were the current agency policies. During an interview with the Adm 10/26/2023 at approximately 3:50 p.m., the surveyor asked what the agency’s processes were for the agency EP plan/program. The Alt Adm stated that agency planned “ahead [and] when things come up” the agency nurses contacted the agency’s clients and checked on them. The DON stated that the agency kept watch for weather reports. She also stated that the agency provided the agency’s clients with resources and “we keep up with our staff.” The surveyor discussed the findings and asked why the agency had not completed at least annual internal reviews of the agency’s EP plan for 2021, 2022, and 2023. The Alt Adm stated, “Oversight.” The surveyor also asked how not completing at least annual internal reviews of the agency’s EP plan could adversely affect the agency’s clients. The Alt Adm stated the clients’ health and safety could be affected. Review of agency policies titled "Emergency Preparedness and Response Plan EC. 40 [and]-Addendum EC.40 TX" last reviewed 07/01/23 read in part: " ...PURPOSE I. To ensure the Agency complies with all applicable Federal, State and local emergency preparedness requirements. II. To ensure the Agency develops, establishes, maintains, and implements emergency policies and procedures, based on the risk assessment, emergency plan, communication plan, and testing and training program…Policy II. The Agency will have a written Emergency Preparedness and Response Plan that comprehensively describes identification of potential disasters, including infectious diseases, and its approach to a disaster that could affect the need for its services or the ability to provide those services. The plan will: A. Be based on and include a documented all-hazards risk assessment (facility-based and community-based) that identifies the disasters from natural and man-made causes that are likely to occur in the Agency’s service area…E. Be reviewed and updated, including related polices, at least every two years…[continued review of Addendum EC.40 TX revealed the following] Policy [:] 1…A. The Agency will complete an internal review of the emergency Preparedness and Response Plan at least annually, and after each actual emergency response, to evaluate its effectiveness and update the plan as needed…” Review of the Centers for Medicare and Medicaid Services website at, CMS.gov on 10/31/2023 revealed the following: “An all-hazards approach is an integrated approach to emergency preparedness planning that focuses on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters, including internal emergencies and a man-made emergency (or both) or natural disaster. This approach is specific to the location of the provider or supplier and considers the particular type of hazards most likely to occur in their areas. These may include, but are not limited to, care-related emergencies, equipment and power failures, interruptions in communications, including cyber-attacks, loss of a portion or all of a facility, and interruptions in the normal supply of essentials such as water and food. Rather than managing planning initiatives for a multitude of threat scenarios all-hazards planning focuses on developing capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters…”

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain an EP plan that was based on and included a documented facility-based and community-based risk assessment, utilizing an all-hazards approach, in that: The agency’s EP records did not include a documented risk assessment for three (2021, 2022 and 2023) of three years reviewed. The failure could place the agency’s patients at risk of harm if the agency were not prepared for disasters that were most likely to occur in the agency’s service area. Findings included: During the entrance conference at 11:12 a.m. on 10/23/2023, the Alt Adm self-identified as the disaster coordinator. The Alt Adm identified the DON as the alternate disaster coordinator. The surveyor requested (all) agency emergency preparedness and response plan documents/reports/manuals. Review of the emergency preparedness and response plan binder did not reveal a documented risk assessment, utilizing an all-hazard approach for the years 2021, 2022 and 2023. The EP binder contained the following: A document tilted, "Analysis of Risk Assessment for Potential Disasters." The "…Assessment for Potential Disasters" included potential disaster titles of Natural Disasters, Technological Hazards, Epidemic, and Terrorism. The listed disasters were not designated a “risk level.” The assessment was not completed, signed, or dated by the Alt Adm, DON, or other agency representative. The binder also contained an agency policy for emergency preparedness dated 01/13/18. During an interview with the DON on 10/25/2023 at 1:59 p.m. the surveyor asked if the agency had provided all agency’s requested records for the agency’s EP program. The DON stated, “Yes.” The surveyor asked who at the agency was responsible for the agency’s EP program. The DON stated that she and the Alt Adm were responsible for the program. During an interview with the Alt Adm on 10/26/2023 at 4:00 p.m. the surveyor asked which (01/13/18 or 07/01/23, online policy) agency policy was the current policy used by the agency. The Alt Adm stated the online policies were the current agency policies. During an interview with the Adm 10/26/2023 at approximately 3:50 p.m., the surveyor asked what the agency’s processes were for the agency EP plan/program. The Alt Adm stated that agency planned “ahead [and] when things come up” the agency nurses contacted the agency’s clients and checked on them. The DON stated that the agency kept watch for weather reports. She also stated that the agency provided the agency’s patients with resources and “we keep up with our staff.” The surveyor discussed the findings and asked why the agency's EP plan did not include a documented risk assessment, utilizing an all-hazards approach for 2021, 2022, and 2023. The Alt Adm stated, “Oversight.” The surveyor also asked how not completing a risk assessment could adversely affect the agency’s patients. The Alt Adm stated the patients’ health and safety could be affected. Review of agency policies titled "Emergency Preparedness and Response Plan EC. 40 [and]-Addendum EC.40 TX" last reviewed 07/01/23 read in part: " ...PURPOSE I. To ensure the Agency complies with all applicable Federal, State and local emergency preparedness requirements. II. To ensure the Agency develops, establishes, maintains, and implements emergency policies and procedures, based on the risk assessment, emergency plan, communication plan, and testing and training program…Policy II. The Agency will have a written Emergency Preparedness and Response Plan that comprehensively describes identification of potential disasters, including infectious diseases, and its approach to a disaster that could affect the need for its services or the ability to provide those services. The plan will: A. Be based on and include a documented all-hazards risk assessment (facility-based and community-based) that identifies the disasters from natural and man-made causes that are likely to occur in the Agency’s service area…E. Be reviewed and updated, including related polices, at least every two years…[continued review of Addendum EC.40 TX revealed the following] Policy [:] 1…A. The Agency will complete an internal review of the emergency Preparedness and Response Plan at least annually, and after each actual emergency response, to evaluate its effectiveness and update the plan as needed…” Review of the Centers for Medicare and Medicaid Services website at, CMS.gov.medicare on 10/31/2023 revealed the following: “An all-hazards approach is an integrated approach to emergency preparedness planning that focuses on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters, including internal emergencies and a man-made emergency (or both) or natural disaster. This approach is specific to the location of the provider or supplier and considers the particular type of hazards most likely to occur in their areas. These may include, but are not limited to, care-related emergencies, equipment and power failures, interruptions in communications, including cyber-attacks, loss of a portion or all of a facility, and interruptions in the normal supply of essentials such as water and food. Rather than managing planning initiatives for a multitude of threat scenarios all-hazards planning focuses on developing capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters…”

A recertification inspection survey was conducted on 10/23/2023. The licensed and certified home health services census was 27. Abbreviations/Acronyms: Adm-Administrator Alt Adm -Alternate Administrator DON-Director of Nursing ADON-Alternate Director of Nursing Registered Nurse (RN) Physical Therapist (PT) EHR- Electronic Health Record POC- Plan of Care SOC- Start of Care HHA- Home Health Agency SN- Skilled Nursing hha-home health aide CMS- Center for Medicare and Medicaid Services OASIS -outcome and assessment information set NOMNC-Notice of Medicare Non-Coverage PIP- Performance Improvement Projects QAPI-Quality Assessment Performance Improvement CDC- Centers for Disease Control COVID-19- Novel Coronavirus Disease 2019 LA-Los Angeles

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure proper written notice was provided, in advance of terminating on-going care in two (Patients # 6 and 7) of two inactive patient records reviewed. The agency failed to provide Patients # 6 and 7 with the Centers for Medicare and Medicaid form titled Notice of Medicare Non-Coverage. The failure could affect patients’ health and safety and result in harm due to lack of physician oversight in the patients’ continuing care and post discharge needs. Findings included: Clinical Record # 6: Record review of the EHR for Patient # 6 revealed a POC with a SOC date of 07/27/2022. The POC had a certification period 07/27/2022 to 09/24/2022 and a principal diagnosis of hypertensive heart disease with heat failure (a disease caused by long term elevated blood pressure). The POC was signed by the DON and dated 07/27/2022. The POC contained an order for SN, hha, and PT services. Patient # 6's record included a PT discharge summary signed by PT A and dated 08/31/2022. The discharge summary listed the reason for discharge as “change in insurance.” The record also included an agency discharge summary dated 09/02/2022 and signed by the DON. Patient # 6's records did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 09/02/2022. The record did not include a written NOMNC. Clinical Record # 7: Record review of the EHR for Patient # 7 revealed a POC with a SOC date of 05/09/2023. The POC had a certification period 07/08/2023 to 09/05/2023 and a principal diagnosis of encounter for orthopedic aftercare following surgical amputation (home health care provided after surgical removal of a body part). The POC was not signed or dated by an agency RN. The record also included a PT POC dated 07/14/2023 and signed by PT B. The POC included orders for PT services for one time per week for one week and two times per week for two weeks. Patient # 7's record included a PT discharge summary signed by PT B and dated 07/29/2023. The discharge summary listed the reason for discharge as “due to unexpected [discharge] due to discharge from agency.” The record also included an agency discharge summary with reason for discharge listed as “goals met” dated 08/24/2023 and signed by the DON. Patient # 7's records did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on, 08/24/2023. The record did not include a written NOMNC. In an interview with the Alt Adm and DON on 10/27/2023 at approximately 11:30 a.m., the surveyor discussed the findings of why the agency had not provided proper written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for Patients # 6 and 7 and who at the agency was responsible for ensuring the notices were provided. The DON stated that she was responsible and it (patient change in insurance) “kind of caught us off guard.” The surveyor also asked how not providing proper written notice no later than two days in advance of terminating on-going care could adversely affect the patients. The DON stated it could affect the patients’ continuity (unbroken, consistent, continue) of care after discharge. Agency policy titled “Patient/Client Transfer and Discharge Notices PE.30” last reviewed 08/01/20 read in part: “…Policy…I... Prior to transferring or discharging a patient/client, the Agency will provide written notification to the patient/client or the patient’s/client’s family …III. The Agency will deliver the Notice of Medicare Non-Coverage…to the patient/client or representative, at least two…calendar days before Medicare covered services end, or the second to last day of service if care is not provided daily…”

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct and document Performance Improvement Projects, which reflected the scope, complexity, and past performance of the agency's services and operations for three (2021, 2022, and 2023) of three years reviewed. The failure could place patients’ health and safety at risk if the agency did not identify health and safety concerns and develop improvement projects to address the concerns. Findings included: During the entrance conference on 10/23/2023 at 11:12 a.m., the surveyor requested all agency QAPI binders/reports/documents. Record review of the QAPI records revealed the following reports: QAPI reports titled “QAPI Findings, Goals, and Recommendations” dated: 3/24/21 for 4th Quarter 2020; 6/29/21 for 1st Quarter 2021; 11/10/21 for 2nd Quarter 2021; 1/18/22 for 3rd Quarter 2021; 1/25/23 for 3rd quarter 2022; 5/10/23 for 4th Quarter 2022; and 8/9/23 for 1st Quarter 2023. Continued review of the QAPI records revealed four “QAPI ACTION Plan[s]” dated 1/18/2022. The QAPI plans were signed and dated by agency consultant (Identifier 100) on 1/18/2022. The action plans were not completed by the agency to provide results and or/follow-up of the plans. Continued review of the agency’s QAPI records did not reveal any documentation that showed the agency had any performance improvement project(s) either in development, on-going or completed for the years 2021, 2022 and 2023. During an interview with the DON on 10/25/2023 at 1:59 p.m. the surveyor asked if the agency had provided all agency’s requested records for the agency’s QAPI program. The DON stated, “Yes.” The surveyor asked who at the agency was responsible for the agency’s QAPI program. The DON stated that she was responsible for the program. During an interview with the Alt Adm and DON on 10/26/2023 at 4:06 p.m. the surveyor asked what the agency’s processes were for its QAPI program. The DON stated, “Our biggest thing is we have someone come in from [consulting agency, Identifier 200]. She goes over some things with us for education purposes.” The surveyor asked what the agency did after the consultant (Identifier 100) submitted the QAPI reports to the agency. The DON stated that the agency conducted in-services and “try to go with more correct data in the day-to-day charting.” The DON also stated that the agency had someone at the agency who reviewed the OASIS data but was in the process of finding someone to review the remainder of the agency’s QAPI data. The surveyor discussed the findings and asked why the agency had not conducted PIPs. The DON replied, “I guess, I need to actually look at it myself. I just took on this role at the first of the year.” The surveyor asked how not implementing, maintaining and documenting the agency’s QAPI program in accordance with state, federal regulations and in accordance with agency policy could adversely affect the agency’s patients. The DON stated that it could cause something to be “dropped in the patients’ needs. Even the [patient’s physicians] not being notified of their needs.” Review of agency policy titled “Performance Improvement Process: Improvement Activities QAPI.25” last reviewed 01/13/18 read in part: “Purpose [:] To establish a standard for achieving and sustaining improved performance. Policy 1. The Governing Body will be responsible for setting the priorities for improvement activities or projects based on Agency functions…II. The Governing Body will determine the number and scope of distinct Performance Projects…conducted annually. III. When developing and prioritizing the improvement activities or projects, the Governing Body will consider…A. The scope, complexity, and past performance of the Agency’s services and operations…IV. All performance improvement activities/projects undertaken will be documented and include the reasons for conducting and the measurable progress achieved…” Review of agency policy titled, “"Quality Assessment Performance Improvement Program QAPI.5" last reviewed 01/13/18 read in part: “Purpose [:] To develop, implement, evaluate, and maintain an effective, ongoing, Agency-wide, data-driven…QAPI Program as defined by its QAPI Plan…Policy…II. The Agency will focus primarily on its processes and/or system performances rather than an individual’s performance yet will recognize the importance of the competence of the staff…IV. Executive responsibilities. The Agency’s Governing Body is responsible for ensuring…A. That an ongoing program for quality improvement and patient/client safety is defined, implemented, and maintained; B. That the Agency-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient/client safety, and that all improvement actions are evaluated for effectiveness…III. Program Activities…3. Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patient/clients…5. Lead to actions aimed at performance improvement, and, after implementing those actions will measure the success and track performance to ensure improvements are sustained…”

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on record review and interview the HHA’s governing body failed to ensure that an ongoing program for quality improvement and patient safety was defined, implemented, and maintained; and that the HHA-wide quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety, and that all improvement actions were evaluated for effectiveness for three (2021, 2022, and 2023) of three years reviewed. The agency’s QAPI program failed to include infection control activities that ensured patient safety and failed to implement and/or evaluate for effectiveness of the agency’s improvement efforts. The failure could place patients’ health and safety at risk if the agency did not identify health and safety concerns and develop improvement efforts to address those concerns. Findings included: During the entrance conference on 10/23/2023 at 11:12 a.m., the surveyor requested all agency QAPI binders/reports/documents. Record review of the QAPI records revealed the following reports: QAPI reports titled “QAPI Findings, Goals, and Recommendations” dated: 3/24/21 for 4th Quarter 2020; 6/29/21 for 1st Quarter 2021; 11/10/21 for 2nd Quarter 2021; 1/18/22 for 3rd Quarter 2021; 1/25/23 for 3rd quarter 2022; 5/10/23 for 4th Quarter 2022; and 8/9/23 for 1st Quarter 2023. The QAPI quarterly reports did not include the agency’s infection control activities for 2021, 2022, and 2023. The QAPI records also did not reveal that the agency had implemented and/or evaluated for effectiveness of the agency’s improvement efforts for the years 2021, 2022 and 2023. Continued review of the QAPI records revealed four “QAPI ACTION Plan[s]” dated 1/18/2022. The QAPI plans were signed and dated by agency consultant (Identifier 100) on 1/18/2022. The action plans were not completed by the agency to provide results and or/follow-up of the plans. The QAPI records did not show documentation of corrective or improvement efforts for identified agency areas of concern that showed improvements efforts and that improvements efforts were sustained for 2021, 2022 and 2023. During review of agency’s patient EHRs revealed documented reports of patient infections (Patients # 2, 5, 11, 12, 17, 18, 19, 20, 22, 23, 25, 26, and 28) from 02/15/2021 through 09/26/2023. The type of infections that were document included the following: wound; urinary; upper and lower respiratory; surgical wound; dental, and COVID-19 infections. During an interview with the DON on 10/25/2023 at 1:59 p.m. the surveyor asked if the agency had provided all agency’s requested records for the agency’s QAPI program. The DON stated, “Yes.” The surveyor asked who at the agency was responsible for the agency’s QAPI program. The DON stated that she was responsible for the program. During an interview with the Alt Adm and DON on 10/26/2023 at 4:06 p.m. the surveyor asked what the agency’s processes were for its QAPI program. The DON stated, “Our biggest thing is we have someone come in from [consulting agency, Identifier 200]. She goes over somethings with us for education purposes.” The surveyor asked what the agency does after the consultant (Identifier 100) submits the QAPI reports to the agency. The DON stated that the agency conducts in-services and “try to go with more correct data in the day-to-day charting.” The DON also stated that the agency had someone at the agency who oversees the OASIS data review but was in the process of finding someone to review the remained of the agency’s QAPI program. The surveyor discussed the findings and asked why the agency had not followed-up with action plans for the areas of concern in the agency’s QAPI reports and maintained a QAPI Program that included the following required elements: infection control activities, an annual evaluation of the agency’s total operations, document corrective action to ensure that improvements were sustained over time. The DON replied, “I guess, I need to actually look at it myself. Maybe we didn’t talk in detail to the whole group (staff). I guess I did it on a one-one level. I just took on this role at the first of the year.” The surveyor asked how not implementing, maintaining and, documenting the agency’s QAPI program in accordance with state, federal regulations and in accordance with agency policy could adversely affect the agency’s patients. The DON stated that it could cause something to be “dropped in the patients’ needs. Even the [patient’s physicians] not being notified of their needs.” Review of agency policy titled, “"Quality Assessment Performance Improvement Program QAPI.5" reviewed 01/13/18 read in part: “Purpose [:] To develop, implement, evaluate, and maintain an effective, ongoing, Agency-wide, data-driven…QAPI Program as defined by its QAPI Plan…Policy…II. The Agency will focus primarily on its processes and/or system performances rather than an individual’s performance yet will recognize the importance of the competence of the staff…IV. Executive responsibilities. The Agency’s Governing Body is responsible for ensuring…A. That an ongoing program for quality improvement and patient/client safety is defined, implemented, and maintained; B. That the Agency-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient/client safety, and that all improvement actions are evaluated for effectiveness…III. Program Activities…3. Lead to an immediate correction of any identified problem that directly or potentially threaten the health and safety of patient/clients…5. Lead to actions aimed at performance improvement, and, after implementing those actions will measure the success and track performance to ensure improvements are sustained…” Review of agency policy titled "Quality Assessment Performance Improvement Program-Addendum QAPI.5 TX" last reviewed 04/14/23 read in part: " Procedure 1. In addition to the requirements defined in the Quality Assessment Performance Improvement program policy in the Quality Assessment Performance Improvement section of the Administrative Policy Manual, the following requirements will also be met: A. The Agency will maintain a Quality Assessment and Performance Improvement program that is implement by a QAPI Committee…E. The QAPI plan will be reviewed and updated at least once within the calendar year…" Review of agency policy titled, Agency Evaluation Process QAPI. 45-TX” last reviewed 04/14/23 read in part: “Purpose [:] To outline the process for performing an annual agency evaluation and assess Agency’s program for appropriateness, adequacy, effectiveness, and efficiency. Policy [:] The Agency leaders…will participate in an annual evaluation of the organization’s performance…Procedure [:] 1. The agency must use the evaluation to correct identified problems and…revise policies. II. The Agency must document corrective action to ensure that improvements are sustained over time…C. A written summarization with recommendations for improvement change will be presented to the Governing Body annually and retained at the Agency’s administrative offices…”

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain a coordinated agency‐wide program for the surveillance, identification, prevention, control, and investigation of infectious and/or communicable diseases that was an integral part of the Home Health Agency's QAPI program for three (2021, 2022 and 2023) of three years reviewed. The agency failed to include in its infection control program: a method for identifying infectious and communicable disease problems; and a plan for the appropriate actions that were expected to result in improvement and disease prevention. The failure could place agency patients’ health and safety at risk due to an increased risk of the spread of infectious and/or communicable diseases. Findings included: During the entrance conference on 10/23/2023 at 11:12 a.m., the surveyor requested the agency’s infection control records. During an interview with the DON at 2:00 p.m. the surveyor again requested the agency’s infection control records. Review of the agency’s infection control records revealed the following: A “Texas COVID-19 Weekly Surveillance Report” for the years 2023, 2022, and 2021; Monthly Calendars for the years 2023, 2022, and 2021 that did not document or reveal any patient infections for the years 2021, 2022 and 2023; and an agency Infection Control Policy dated 01/13/18. The agency did not provide any records that revealed the agency had maintained a coordinated agency‐wide program for the surveillance, identification, prevention, control, plan of action, and investigation of infectious and/or communicable diseases that was an integral part of the Home Health Agency's QAPI program for the years 2021, 2022, and 2023. During an interview with the DON on 10/25/2023 at 1:59 p.m. the surveyor asked if the agency had provided all agency’s requested records for the agency’s infection control program. The DON stated, “Yes.” The surveyor asked who at the agency was responsible for the agency’s infection control program. The DON stated that she was responsible for the program. During review of agency’s patient EHRs revealed documented reports of patient infections (Patients # 2, 5, 11, 12, 17, 18, 19, 20, 22, 23, 25, 26, and 28) from 02/15/2021 through 09/26/2023. The type of infections that were document included the following: wound; urinary; upper and lower respiratory; surgical wound; dental, and COVID-19 infections. During an interview with the Alt Adm on 10/26/2023 at 4:00 p.m. the surveyor asked which (01/13/18 or 12/17/22 and 04/14/23, online policies) agency policy was the current policy used by the agency. The Alt Adm stated the online policies were the current agency policies. During an interview with the Alt Adm and DON on 10/26/2023 at approximately 3:30 p.m. The surveyor asked what the agency’s processes were for the infection control program. The DON replied, “That one has been a work in hand. When they (patients) are on antibiotics, we have a form (Patient/Employee Infection Report) that is completed.” The surveyor discussed that the form had not been completed for the agency’s patient infections that were in the agency’s EHRs. The surveyor asked why patient infection surveillance, a plan of action and analysis had not been included in the agency’s infection control and QAPI program. The DON replied, “It is just that the person who has been doing it (QAPI) has not caught it.” The surveyor asked, “who is responsible?” The DON stated, “Nobody at this second, but we are in the process of finding someone.” The surveyor also asked how not maintaining the agency infection control program could adversely affect the agency’s patients. The DON stated that it could affect their safety if they had a reaction to an antibiotic and it could cause infectious and/or communicable disease to spread. Review of agency's policy titled "Infection Control Program-Addendum IC 10-TX” last reviewed 12/17/22 read in part: “Policy [:] 1. In addition to the Policy Statement in the Infection Control Program in the Surveillance, Preventions and Control of Infection section of the Administrative Policy Manual…Procedure…1…the agency will adhere to the following requirements: A. Coordinated Activities: 1. Surveillance Activities a. There are three surveillance methods: Total…Total surveillance will be used to meet Texas Health and Human Services…regulations…” Review of Agency policy titled “Infection Control Program IC. 10” last reviewed 04/14/23 read in part: “Purpose [:] To outline the policies and procedures for an infection control program which applies to patients/clients, staff and care provided. The program improves patient/client health outcomes through risk reduction, prevention, identification, and control of infections and communicable diseases in patients/clients and staff. Policy 1. Agency's infection control program will be based on the following criteria ...Current scientific methods of surveillance and prevention or control of adverse outcomes related to infections. CDC guidelines updated annually...Current federal, state and local laws and regulations ...II. The infection control program will include: A. Assignment of responsibilities…C. A system that coordinates: 1. Surveillance for the occurrence of an infection 2. Identification of the occurrence…5. Review of the data collected to evaluate for trends, patterns…III…B. Identification and Investigation Activities 1. Analyze data for problems or undesirable trends…D. Review and Reporting activities...4. The clinical manager, or designee, will review all reports and analyze the data, noting trends or patterns and will report to the Governing Body quarterly. 5. When trends and significant occurrences are identified, a review will be initiated…to formulate plans for appropriate actions to improve infection control and disease prevention. 6. A composite of infection control data will be presented to the Governing Body annually…8. The Agency will track all infections… " Review of the American Medical Association Journal website, https://journalofethics.ama-assn.org/article/surveillance-infectious-diseases-information-action/2006-04, on 09/15/2023 revealed the following: “...Surveillance is defined as the “ongoing, systematic collection, analysis, and interpretation of outcome-specific data for use in the planning, implementation, and evaluation of public health practice…” Review of the Britannica Dictionary website, https://www.britannica.com/dictionary/surveillance, on 09/15/2023 revealed the following definition for surveillance: …the act of carefully watching… something especially in order to prevent or detect…” Review of the LA County Department of Public Health website at, Healthhttp://ndhealth.gov/disease/hai/Presentation/Surveillance_of_Infections.pdf, on 10/30/2023 revealed the following definition for total surveillance, “Total…surveillance monitors all…[infections] in the entire facility…”