Every finding on record at First Choice Home Health Services Inc

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to obtain the patient's or legal representative's signature confirming that a copy of the notice of rights and responsibilities was received in 1 of 3 active clinical records reviewed. (#1) The findings include: Review of an undated agency policy, obtained 6/7/2021, titled "Rights/Responsibilities" stated, "... The patient or legal representative will be requested to sign the Patient Rights and Responsibilities form. The original form will be kept in the patient's clinical record. A copy will be maintained by the patient. The patient's refusal to sign will be documented in the clinical record, including the reason for refusal...." Clinical record review on 6/3/2021 and 6/7/2021 for patient #1, start of care 3/11/2021, evidenced an undated agency document titled "Patient Rights and Responsibilities". This form failed to evidence the patient or the patient's legal representative signed a copy of the notice of rights and responsibilities. During an interview on 6/4/2021 at 10:51 AM, the administrator indicated the patient's admission consents were not in the chart to include the signed patient rights and responsibilities form. During an interview on 6/4/2021 at 10:51 AM, the alternate clinical manager indicated the agency has had difficulty getting the signed consents to transfer from the clinician's phone once the patient or legal representative signed them into the electronic clinical record. 17-12-3(a)(2)

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure all verbal orders were recorded in the plan of care for 1 of 1 closed record reviewed. (#4) The findings include: Review of an undated agency policy, obtained 6/7/2021, titled "Care Planning Process" stated, " ... Based on the assessment and conclusions, the plan of care will include, but not be limited to: ... All patient care orders from all physicians involved in the plan of care including verbal orders ... The plan of care will be revised as frequently as deemed necessary by the clinician, based on the ongoing assessments of the patient ... Clinicians will inform the patient's physician of any changes that suggest a need to alter the plan of care ...." Clinical record review on 6/6/2021 for patient #4, start of care 5/17/2021, evidenced an agency document titled "Home Health Certification and Plan of Care" for certification period 5/17/2021 - 7/15/2021. The patient's medication failed to evidence Ibuprofen (a medication to treat pain and inflammation). Review of an agency document titled "OASIS D1-Start of Care", electronically signed by the alternate clinical manager and dated 5/17/2021, indicated the patient's pain was rated 7 on a scale from 0-10. During an interview on 6/7/2021 at 12:11 PM when queried what the intervention was for the patient's pain during the initial comprehensive assessment identified on 5/17/2021, the alternate administrator indicated she administered 400 milligrams of Ibuprofen to the patient. The alternate clinical manager indicated she contacted the patient's physician for the verbal order for the Ibuprofen but forgot to write the order. The alternate clinical manager indicated she did not include the Ibuprofen in the plan of care since it was a one-time order.

Aides are members of interdisciplinary team CFR(s): 484.80(g)(4) Home health aides must be members of the interdisciplinary team, must report changes in the patient's condition to a registered nurse or other appropriate skilled professional, and must complete appropriate records in compliance with the HHA's policies and procedures. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure all home health aides reported changes in the patient's condition for 1 of 2 home visits conducted. (#2) The findings include: Clinical Record review on 6/7/2021, for patient #2, start of care 3/11/2021, evidenced two agency documents titled "Home Health Certification and Plan of Care", for certification period 5/10/2021 - 7/8/2021. These documents were identified by the administrator as one plan of care for the Medicare-covered services and one plan of care for the Medicaid-covered services. The administrator indicated the Medicare plan of care was identified with the medical record number beginning with "MR" and the Medicaid plan of care was identified with the medical record number beginning with "HHA". The plan of care that had a medical record starting with "MR" and was electronically signed by physician F on 6/4/2021. This document had an area subtitled "10. Medications" which indicated the patient was prescribed Baclofen, Ocrevus and Ibuprofen. An area subtitled "21. Orders for Discipline and Treatments (Specific Amount/Frequency/Duration) stated " ... HHA [home health aide] provides all ADL [activities of daily living] care during the day, and family checks on [him/her] in the evening ... HHA 7- 8h/v- 5 - 7v/wk x's [7 to 8 hour visits, 5 to 7 days a week, for] 9 weeks Funded by Medicaid ... HHA PRN Visits for care up to 2h/wk [2 hours per week] ... HHA 2/wk x's [twice per week for] 9 weeks Medicare funded ...." Review failed to evidence a home health aide care plan associated with the "MR" . The Medicaid plan of care failed to indicate it was reviewed by the physician. An area subtitled "21. Orders for Discipline and Treatments (Specific Amount/Frequency/Duration) stated " ... HHA provides all ADL care during the day, and family checks on [him/her] in the evening ... HHA 7- 8h/v- 5 - 7v/wk x's 9 weeks Funded by Medicaid ... HHA PRN Visits for care up to 3h/wk [3 hours per week] ...." This document failed to evidence the patient had medications ordered/prescribed. Review of an agency document titled, "Home Health Aide Care Plan" which was electronically signed by the alternate clinical supervisor on 5/10/2021 for the clinical record starting with "HHA". This document had a list of tasks to be performed by the HHA, for the patient, and stated "Medication Reminder ... Daily ...." During an interview on 6/4/2021, at 12:33 PM, HHA D queried what to do about a new medication prescribed by physician F. HHA D indicated they do not understand why a beta blocker (medication used to manage abnormal heart rhythms) would be prescribed right before physician F retired. Review failed to evidence HHA D informed the alternate clinical supervisor about a new medication. During an interview on 6/4/2021, at 1:36 PM, HHA D indicated she is afraid to give the patient a new medication because it might make the patient lethargic. HHA D indicated they had not picked up the new medication from the pharmacy yet, but would call the alternate clinical supervisor when she did. HHA D indicated it was odd that physician F resigned and then put the patient on a beta blocker, because the patient has been in the same condition for a long time. During an interview on 6/7/2021, at 4:27 PM, the administrator stated, "We are essentially family" for some patients. The administrator indicated it is not agency policy for a HHA to give medications. The administrator indicated it is not on the care plan for HHA D to pick up medications for the patient.

Goals in the patient's plans of care CFR(s): 484.110(a)(3) Goals in the patient's plans of care and the patient's progress toward achieving them; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record included the patient's goals and progress towards the goals in the plan of care in 3 of 4 clinical records reviewed. (#1, #3, #4) The findings include: 1. Review of an undated agency policy, obtained 6/7/2021, titled "Entries Into The Clinical Record" stated, "... Home health personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. The record format will be reviewed and updated as necessary ... A clinical record will be initiated and maintained for each patient receiving care or services, according to organization policies found in this manual, and will include at a minimum: ... Patient response to care and services analyzed and documented as measurable goals G. Current patient status and progress toward goals ...." 2. Clinical record review on 6/3/2021 and again on 6/7/2021 for patient #1, start of care 3/11/2021 with diagnoses, including but not limited to, Stage II pressure ulcer (a type of wound which typically develops when soft tissue is compressed between a bony prominence and an exterior surface for an extended period of time resulting in partial thickness skin loss) of right buttock and multiple sclerosis (a disease of the brain and spinal cord causing permanent damage or deterioration of the nerves), evidenced an agency document titled "Physician Order". This document was dated 4/13/2021 and electronically signed by the alternate clinical manager, and indicated the patient was to receive physical therapy services 1 time per week for range of motion, bed mobility and transfer training. Review of the agency's electronic health record evidenced documents titled "Physical Therapy Progress Visit", dated 5/13/2021 and 5/20/21, which stated, "In Progress". During an interview on 6/4/2021 at 10:50 AM, the administrator indicated the patient received physical therapy services 1 time per week. The administrator indicated he was the physical therapist conducting the visits and indicated the patient's physical therapy goals were to sit and working with her in her power wheelchair. The administrator indicated the patient has received physical therapy services weekly since the physician's order was obtained on 4/13/2021. Review of an agency document titled "Home Health Certification and Plan of Care" for certification period 5/10/2021 - 7/8/2021, electronically signed by the clinical manager on 5/5/2021, was identified by the administrator as the Medicare plan of care. Review failed to evidence the plan of care included patient-specific goals related to the physical therapy services provided. 3. Clinical record review on 6/6/2021 for patient #3, start of care 5/16/2021 and a primary diagnosis of Alzheimer's Disease (a gradually progressive brain disorder which causes problems with memory, thinking and behavior), evidenced an agency document titled "Home Health Certification and Plan of Care" for certification period 5/16/2021 - 7/14/2021. This document indicated the patient was homebound due to the patient had dementia and poor safety awareness and was unable to safely ambulate, and the plan of care failed to evidence patient-specific goals. 4. Clinical record review on 6/6/2021 for patient #4, start of care 5/17/2021 and a primary diagnosis of malignant neoplasm of bilateral breasts (cancerous tumor to both breasts), evidenced an agency document titled "OASIS D1-Start of Care", electronically signed by the alternate clinical manager and dated 5/17/2021 and identified to be the initial comprehensive assessment. This document indicated the patient had a surgical wound to the right breast and a surgical wound to the left breast, each with a surgical drain and 3 stitches. This document indicated the skilled nurse cleansed the wounds with alcohol, covered with a bio patch (a foam patch with topical antiseptic used to prevent infection) and applied a tegaderm dressing (a transparent film wound dressing). Review of an agency document titled "Home Health Certification and Plan of Care" for certification period 5/17/2021 - 7/15/2021, failed to evidence patient-specific goals related to the patient's surgical wounds. During an interview on 6/7/2021 at 12:38 PM, the alternate clinical manager indicated the plan of care should be individualized and complete to include the patient's goals related to the wounds which were to reduce the drainage and stay free of signs and symptoms of infection. 5. During an interview on 6/7/2021 at 12:38 PM, the alternate clinical manager indicated the plan of care should be individualized and complete to include goals.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(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 develop and maintain a comprehensive emergency preparedness plan that is reviewed and updated at least every 2 years. The findings include: Review of an undated agency policy titled "Emergency Management Plan" stated, "... The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations. The organization will establish an all-hazards approach to emerging preparedness that focuses on identifying hazards and developing emergency preparedness capabilities ... The HVA [hazard vulnerability analysis] is evaluated at least every two (2) years to reflect changes in organization, risk conditions, patient information and changes in staff...." Review of the agency's emergency preparedness plan on 3/11/2021, evidenced an undated document titled "Emergency Preparedness Manual for Home Care Providers" which failed to evidence the emergency preparedness plan was reviewed and updated at least every 2 years. Review of agency policies provided on 3/12/2021, titled "Communication Plan Policy", "Emergency Preparedness Policies and Procedures EDP Patient Admission", "Evacuation Policy", "Emergency Disaster Plan Orientation and Training Policy" and "Command Center" which evidenced blanks for "date reviewed" and "reviewed by" which failed to evidence a date reviewed or who reviewed the policies. During an interview on 3/12/2021 at 10:45 a.m., when queried how the agency reviewed and updated the emergency preparedness plan, the administrator indicated he put the papers in the binder. When queried how the agency ensured the emergency preparedness plan was reviewed at least every two years, the administrator indicated he signed some of the forms. The administrator indicated he did not expect the surveyors until next week. No further documentation was provided.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(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 LTC facilities at §483.73(a)(1):] 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)(1):] 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. * [For Hospices at §418.113(a)(2):] 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. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain a comprehensive emergency preparedness plan which included a documented, facility-based and community-based risk assessment utilizing an all-hazards approach and included strategies for addressing emergency events identified by the risk assessment. The findings include: Review of an undated agency policy titled "Emergency Management Plan" stated, "... Organization leadership will conduct a hazard vulnerability analysis (HVA) to identify potential emergencies (risks) that could impact the need for services or the ability to provide care to the patients ... Establishing priorities among the potential emergencies identified in the hazard vulnerability analysis...." Review of an undated policy titled "Safety/Emergency Preparedness" stated, "... The plan will be community based and use the Risk Based Analysis Assessment. ... The plan will include but is not limited to: ... Community Based Risk Assessment ...." Review of the agency's emergency preparedness plan on 3/11/2021, evidenced an undated document titled "Emergency Preparedness Manual for Home Care Providers" which evidenced a document titled "Hazard Vulnerability Assessment Tool" which evidenced the document to be blank. Review failed to evidence a facility-based and community-based risk assessment. No further documentation was provided. During an interview on 3/12/2021 at 10:45 a.m., the administrator indicated everything for emergency preparedness was in the binder.

EP Program Patient Population CFR(s): 484.102(a)(3) [(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:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a)(3):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness plan which addressed patient population. The findings include: Review of an undated agency policy titled "Emergency Management Plan" stated, "... The organization will comply with all applicable, Federal State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations...." Review of the agency's emergency preparedness plan on 3/11/2021, evidenced an undated document titled "Emergency Preparedness Manual for Home Care Providers" which failed to address the patient population. During an interview on 3/12/2021 at 10:45 a.m., the administrator indicated everything for emergency preparedness was in the binder.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years (annually for LTC facilities). The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness plan which included a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The findings include: Review of an undated agency policy titled "Emergency Management Plan" stated, "... The organization will comply with all applicable, Federal State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations ... The plan includes the following: ... A means of informing tribal, regional, federal, state and local emergency preparedness officials before, during and after an emergency, in an effort to maintain an integrated response curing [sic] a disaster or emergency situation ...." Review of the agency's emergency preparedness plan on 3/11/2021. evidenced an undated document titled "Emergency Preparedness Manual for Home Care Providers" which included a document titled "Emergency Management Agencies". Review evidenced contact information for emergency officials in the State of Maryland and the District of Columbia. Review failed to evidence the plan included a process for cooperation and collaboration with local, regional, and state emergency preparedness officials during an emergency situation for which the agency was located. During an interview on 3/12/2021 at 10:45 a.m., the administrator indicated everything for emergency preparedness was in the binder. The administrator indicated he was unsure why the contact information was for agencies located in Maryland.

Development of EP Policies and Procedures CFR(s): 484.102(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. *[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 develop and implement emergency preparedness policies and procedures based on the risk assessment and reviewed and updated at least every 2 years. The findings include: Review of an undated agency policy titled "Emergency Management Plan" stated, "... The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations. The organization will establish an all-hazards approach to emerging preparedness that focuses on identifying hazards and developing emergency preparedness capabilities ... The HVA [hazard vulnerability analysis] is evaluated at least every two (2) years to reflect changes in organization, risk conditions, patient information and changes in staff...." Review of an undated policy titled "Safety/Emergency Preparedness" stated, "... The plan will be community based and use the Risk Based Analysis Assessment. ... The plan will include but is not limited to: ... Community Based Risk Assessment...." Review of the agency's emergency preparedness plan on 3/11/2021, evidenced an undated document titled "Emergency Preparedness Manual for Home Care Providers" which included a document titled "Hazard Vulnerability Assessment Tool". Review evidenced the document to be blank. Review evidenced the manual was created by the Maryland-National Capital Homecare Association in partnership with Maryland Department of Health and Mental Hygiene Office of Preparedness and Response and included a document titled "Hurricanes" which stated, "... The Atlantic Ocean hurricane season is June 1 to November 30...." Review failed to evidence a risk assessment and the policies and procedures were based on the risk assessment. Review of agency policies provided on 3/12/2021, titled "Communication Plan Policy", "Emergency Preparedness Policies and Procedures EDP Patient Admission", "Evacuation Policy", "Emergency Disaster Plan Orientation and Training Policy" and "Command Center" which evidenced blanks for "date reviewed" and "reviewed by" which failed to evidence a date reviewed or who reviewed the policies. Review failed to evidence the policies and procedures were reviewed and updated at least every 2 years. During an interview on 3/12/2021 at 10:45 a.m., when queried how the agency reviewed and updated the emergency preparedness policies, the administrator indicated he put the papers in the binder. When queried how the agency ensured the emergency preparedness policies were reviewed at least every two years, the administrator indicated he signed some of the forms. The administrator indicated he did not expect the surveyors until next week. No further documentation was provided.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) [(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:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and implement individualized emergency preparedness plans for the patients which provided appropriate instructions, in the event of an emergency, to communicate with the agency in 3 of 6 clinical records reviewed. (#1, #3, #5) The findings include: 1. Review of an undated agency policy titled "Emergency Management Plan" stated, "... The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations. ... Individualized plans for the patients during a natural or man-made disaster will be included as part of the comprehensive patient assessment. ... The organization educates patients and their families on emergency preparedness at the time of admission including where they can go to shelter and what is required by the shelter...." 2. Review of an undated policy titled "Safety/Emergency Preparedness" stated, "... The plan will include but is not limited to: ... Individualized Emergency Plans for each patient completed at admission and reviewed every 6 months ...." 3. Clinical record review on 3/15/2021, for patient #5 evidenced an agency document titled "Disaster Preparedness Plan", electronically signed and dated by the patient and the administrator on 12/18/2020, which stated, "... Disaster Instructions ... Call [agency C] to voice any needs or concerns...." 4. Clinical record review for patient #1, start of care 10/29/2020, evidenced an agency document titled "Disaster Preparedness Plan" dated 10/29/2020, signed by the patient and electronically signed by the clinical manager. This document had an area subtitled "Disaster Instructions" which stated "... 3. Call (Entity C/ home health agency), Inc to voice any needs or concerns...." 5. Clinical record review for patient #3, start of care 02/15/2020, evidenced an agency document titled "Disaster Preparedness Plan" dated 02/15/2020, initialed by the patient and electronically signed by the administrator. This document had an area subtitled "Disaster Instructions" which stated "... 3. Call (Entity C/home health agency), Inc to voice any needs or concerns...." During an interview on 3/23/2021 at 3:44 p.m., the administrator indicated Entity C was the name of the software company.

Homebound HHA/Hospice Inform EP Officials CFR(s): 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 develop and implement emergency preparedness policies and procedures which included procedures to inform State and local emergency preparedness officials about homebound home care patients in need of evacuation from their residences due to an emergency situation. The findings include: Review of an undated agency policy titled "Emergency Management Plan" stated, "... The organization will comply with all applicable, Federal State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations ... The plan includes the following: ... A means of informing tribal, regional, federal, state and local emergency preparedness officials before, during and after an emergency, in an effort to maintain an integrated response curing [sic] a disaster or emergency situation, on the following: ... Patients in need of evacuation due to their medical or behavioral health, or conditions of the home environment...." Review of an undated policy titled "Safety/Emergency Preparedness" stated, "... The plan will be community based and use the Risk Based Analysis Assessment. ... The plan will include but is not limited to: ... Identification of patients with limited mobility ... For homebound patients and patients with limited mobility, inform State and local emergency preparedness officials of the need for patient evacuations if the emergency plan is activated...." Review of the agency's emergency preparedness plan on 3/11/2021, evidenced an undated document titled "Emergency Preparedness Manual for Home Care Providers" which included a document titled "Emergency Management Agencies". Review evidenced contact information for emergency officials in the State of Maryland and the District of Columbia. Review failed to evidence the plan included identification of homebound patients. Review failed to evidence the plan included a process for notifying the State and local emergency preparedness officials, for which the agency was located, of patients in need of evacuation during an emergency situation. During an interview on 3/12/2021 at 10:45 a.m., the administrator indicated everything for emergency preparedness was in the binder. The administrator indicated he was unsure why the contact information was for agencies located in Maryland.

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) [(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 develop and implement emergency preparedness policies and procedures which included procedures to follow-up with on-duty staff and patients to determine services that are needed in the event there is an interruption in services during or due to an emergency and must inform State and local emergency preparedness officials about any on-duty staff or patients they are unable to contact. The findings include: Review of an undated agency policy titled "Emergency Management Plan" stated, "... The organization will comply with all applicable, Federal State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations ... The plan includes the following: ... A means of informing tribal, regional, federal, state and local emergency preparedness officials before, during and after an emergency, in an effort to maintain an integrated response curing [sic] a disaster or emergency situation, on the following: ... Patients that the organization has been unable to contact to determine services needs...." Review of an undated policy titled "Safety/Emergency Preparedness" stated, "... The plan will include but is not limited to: Communication Plan will include but not be limited to; Agency staff ... Call Tree...." Review of the agency's emergency preparedness plan on 3/11/2021, evidenced an undated document titled "Emergency Preparedness Manual for Home Care Providers" which included a document titled "Emergency Management Agencies". Review evidenced contact information for emergency officials in the State of Maryland and the District of Columbia. Review failed to evidence the plan included a process for notifying the State and local emergency preparedness officials, for which the agency was located, of any on-duty staff and patients the agency was unable to contact during an emergency situation. Review failed to evidence the procedures to follow-up with on-duty staff and patients to determine services that are needed. During an interview on 3/12/2021 at 10:45 a.m., the administrator indicated everything for emergency preparedness was in the binder. The administrator indicated he was unsure why the contact information was for agencies located in Maryland.

Development of Communication Plan CFR(s): 484.102(c) (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). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and implement an emergency preparedness communication plan. The findings include: Review of an undated agency policy titled "Emergency Management Plan" stated, "... The organization will comply with all applicable, Federal State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations ... The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated at least every two (2) years...." Review of the agency's emergency preparedness plan on 3/11/2021, evidenced an undated document titled "Emergency Preparedness Manual for Home Care Providers" which failed to evidence a communication plan. During an interview on 3/12/2021 at 10:45 a.m., the administrator indicated everything for emergency preparedness was in the binder.

Names and Contact Information CFR(s): 484.102(c)(1) [(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).] The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness communication plan which included names and contact information for staff, patients' physicians, volunteers and other agencies. The findings include: Review of an undated agency policy titled "Emergency Management Plan" stated, "... The organization will comply with all applicable, Federal State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations ... The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws ... The plan includes the following: ... Names and contact information for the following: ... Staff ... Patients' physicians ... Other sources of assistance...." Review of an undated policy titled "Safety/Emergency Preparedness" stated, "... The plan will include but is not limited to: Communication Plan will include but not be limited to; Agency staff ... Patients physicians ... Other facilities of similar provider or supplies type ... Volunteers...." Review of an undated policy titled "Communication Plan Policy" stated, "... As part of the First Choice overall emergency disaster plan, the agency will establish and maintain a communication plan that complies with Federal, State, and local laws ... The current, updated emergency organizational chart (telephone tree) will clearly identify ... all agency employees ... patient's physicians, volunteers ... The agency will maintain a Staff Notification Tree which will list all personnel, including volunteers and will include the staff member's telephone number ... and alternate means of communication ... The staff emergency organizational chart and the patient roster will include primary and alternate means of communication with all listed...." Review of the agency's emergency preparedness plan on 3/11/2021, evidenced an undated document titled "Emergency Preparedness Manual for Home Care Providers" which included a document titled "Emergency Management Agencies". Review failed to evidence a communication plan that included the contact information for staff, patients' physicians, volunteers and other agencies. During an interview on 3/12/2021 at 10:45 a.m., the administrator indicated everything for emergency preparedness was in the binder.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) [(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).] The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness communication plan which included contact information for Federal, State, tribal, regional, and local emergency preparedness staff and other sources of assistance. The findings include: Review of an undated agency policy titled "Emergency Management Plan" stated, "... The organization will comply with all applicable, Federal State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations ... The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws ... The plan includes the following: ... Contact information for the following: Federal, state, tribal, regional and/or local emergency preparedness staff ... Other sources of assistance...." Review of an undated policy titled "Communication Plan Policy" stated, "... As part of the First Choice overall emergency disaster plan, the agency will establish and maintain a communication plan that complies with Federal, State, and local laws ... The Administrator/designee will be responsible for cooperation, collaboration and maintaining communication with local officials, (Office of Emergency Management), regional, State (State Department of Health) and Federal emergency preparedness officials and community health coalitions ... The Administrator/designee will verify contact information for local, State, Federal officials, community partners and resources on a quarterly basis...." Review of the agency's emergency preparedness plan on 3/11/2021, evidenced an undated document titled "Emergency Preparedness Manual for Home Care Providers" which included a document titled "Emergency Management Agencies". Review evidenced contact information for emergency officials in the State of Maryland and the District of Columbia. Review failed to evidence the plan included contact information for Federal, State, tribal, regional, and local emergency preparedness staff and other sources of assistance for which the agency was located. During an interview on 3/12/2021 at 10:45 a.m., the administrator indicated everything for emergency preparedness was in the binder. The administrator indicated he was unsure why the contact information was for agencies located in Maryland.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) [(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).] The communication plan must include all of the following: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness communication plan which included primary and alternate means for communicating with agency staff and Federal, State, tribal, regional and local emergency management agencies. The findings include: Review of an undated agency policy titled "Emergency Management Plan" stated, "... The organization will comply with all applicable, Federal State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations ... The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws ... The plan includes the following: ... Primary and alternate means for communicating with the staff, federal, State, tribal, regional and local emergency management agencies...." Review of the agency's emergency preparedness plan on 3/11/2021, evidenced an undated document titled "Emergency Preparedness Manual for Home Care Providers" which included a document titled "Emergency Management Agencies". Review evidenced contact information for emergency officials in the State of Maryland and the District of Columbia. Review failed to evidence the plan included primary and alternate means of communicating with agency staff and Federal, State, tribal, regional, and local emergency management agencies. During an interview on 3/12/2021 at 10:45 a.m., the administrator indicated everything for emergency preparedness was in the binder. The administrator indicated he was unsure why the contact information was for agencies located in Maryland.

Methods for Sharing Information CFR(s): 484.102(c)(4)-(5) [(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).] 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 develop and maintain an emergency preparedness communication plan which included a method for sharing information and medical documentation for patient's under the agency's care, as necessary, with other health providers to maintain the continuity of care and a means for providing information about the general condition and location of patients under the agency's care as permitted. The findings include: Review of an undated agency policy titled "Emergency Management Plan" stated, "... The organization will comply with all applicable, Federal State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations ... The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws ... The plan includes the following: ... A method for sharing information and medical documentation for patients under the organization's care as necessary. ... A means of providing information about the general condition and location of patients under the organization's care as permitted...." Review of the agency's emergency preparedness plan on 3/11/2021, evidenced an undated document titled "Emergency Preparedness Manual for Home Care Providers" which failed to evidence a method for sharing information and medical documentation for patient's under the agency's care, as necessary, with other health providers to maintain continuity of care. Review failed to evidence a means for providing information about the general condition and location of patients as permitted. During an interview on 3/12/2021 at 10:45 a.m., the administrator indicated everything for emergency preparedness was in the binder.

Information on Occupancy/Needs CFR(s): 484.102(c)(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).] 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: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness communication plan which included 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. The findings include: Review of an undated agency policy titled "Emergency Management Plan" stated, "... The organization will comply with all applicable, Federal State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations ... The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws ... The plan includes the following: ... A means of providing information about the organization's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee...." Review of an undated policy titled "Communication Plan Policy" stated, "... As part of the First Choice overall emergency disaster plan, the agency will establish and maintain a communication plan that complies with Federal, State, and local laws ... The Administrator/designee will be responsible for cooperation, collaboration and maintaining communication with local officials, (Office of Emergency Management), regional, State (State Department of Health) and Federal emergency preparedness officials and community health coalitions ... The Administrator/designee will verify contact information for local, State, Federal officials, community partners and resources on a quarterly basis...." Review of the agency's emergency preparedness plan on 3/11/2021, evidenced an undated document titled "Emergency Preparedness Manual for Home Care Providers" which included a document titled "Emergency Management Agencies". Review evidenced contact information for emergency officials in the State of Maryland and the District of Columbia. Review failed to evidence the plan included 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. During an interview on 3/12/2021 at 10:45 a.m., the administrator indicated everything for emergency preparedness was in the binder. The administrator indicated he was unsure why the contact information was for agencies located in Maryland.

EP Training and Testing CFR(s): 484.102(d) *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an emergency preparedness training and testing program that is based on the emergency plan, risk assessment, policies and procedures and the communication plan and be reviewed and updated at least every 2 years. The findings include: Review of an undated agency policy titled "Emergency Management Plan" stated, "... The organization will comply with all applicable, Federal State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations ... The training and testing program is reviewed and updated at least every two (2) years. ... The training includes initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under arrangement, and volunteers if applicable. ... First Choice Home Health Services Inc will test the emergency management plan ... at least annually, either in response to an actual emergency or in a planned exercise...." Review of the agency's emergency preparedness plan on 3/11/2021, evidenced an undated document titled "Emergency Preparedness Manual for Home Care Providers" which failed to evidence an emergency preparedness training and testing program. During an interview on 3/12/2021 at 10:45 a.m., the administrator indicated everything for emergency preparedness was in the binder.

EP Training Program CFR(s): 484.102(d)(1) *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to provide and maintain documentation of initial training in emergency preparedness policies and procedures to all new and existing staff and individuals providing services under arrangement and failed to demonstrate staff knowledge of emergency procedures. The findings include: Review of an undated agency policy titled "Emergency Management Plan" stated, "... The organization will comply with all applicable, Federal State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations ... The training and testing program is reviewed and updated at least every two (2) years. ... The training includes initial training in emergency preparedness policies and procedures and their assigned emergency response roles to all new and existing staff, individuals providing service under arrangement, and volunteers if applicable. ... Training will be documented in the personnel record. ... Education to include: ... Specifics of organization's emergency management plan ...." Review of the agency's emergency preparedness plan on 3/11/2021, evidenced an undated document titled "Emergency Preparedness Manual for Home Care Providers" which failed to evidence an emergency preparedness training program. Personnel record review on 3/12/2021, for employee A, B, C, D, E, F, G, H, I, J, K, L, M and N failed to evidence emergency preparedness training was provided. During an interview on 3/12/2021 at 10:45 a.m., the administrator indicated everything for emergency preparedness was in the binder. When queried if emergency preparedness training had been provided to the staff, the administrator indicated he did not expect the surveyors until next week. No further documentation was provided.

EP Testing Requirements CFR(s): 484.102(d)(2) *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d) (2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct exercises to test the emergency plan annually. The findings include: Review of an undated agency policy titled "Emergency Management Plan" stated, "... The organization will comply with all applicable, Federal State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations ... First Choice Home Health Services Inc will test the emergency management plan ... at least annually, either in response to an actual emergency or in a planned exercise...." Review of the agency's emergency preparedness plan on 3/11/2021, evidenced an undated document titled "Emergency Preparedness Manual for Home Care Providers" which failed to evidence exercises to test the emergency preparedness program. During an interview on 3/12/2021 at 10:45 a.m., the administrator indicated everything for emergency preparedness was in the binder. The administrator indicated he did not expect the surveyors until next week. No further documentation was provided.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the correct information for the administrator was provided to all patients at admission in 3 of 6 clinical records reviewed. This standard would affect all patients of the home health agency. (#1, #3, #5) The findings include: 1. The undated agency policy, retrieved 3/23/21, titled "Rights/Responsibilities" Policy No. [number] 1-001.1 stated "Purpose To encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning. Policy Each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights and responsibilities as described. ... Procedure 1. The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care to the patient, of the following: ... V. The contact information for the agency administrator, including the administrator's name, business address, and business phone number in order to receive complaints...." 2. Clinical record review on 3/15/2021 for patient #5, start of care 12/18/19, evidenced an agency document titled "Admission Consent", electronically signed by the patient and the administrator on 12/18/19, which stated, "... If you have any further questions or in the event of a complaint, please contact our Administrator: (phone number for home care agency B in Arizona) ...." Review failed to evidence the document provided the patient the correct contact information for the administrator in order to receive complaints. 3. On 3/15/2021 at 1:14 p.m., a phone call was placed to (phone number for home care agency B in Arizona) which identified to be home care agency B in Arizona. 4. During an interview on 3/22/2021 at 1:40 p.m., the administrator indicated the phone number listed on the Admission Consent document was not correct.5. Clinical record review for patient #1, start of care 10/29/2020, evidenced an agency document titled "Admission Consent" dated 10/29/2020 signed by patient #1 and electronically signed by the clinical manager. This document stated "... IMPORTANT: If you have any further questions or in the event of a complaint, please contact our Administrator: (phone number for home care agency B in Arizona)...." 6. Clinical record review for patient #3, start of care 02/15/2020, evidenced an agency document titled "Admission Consent" dated 02/15/2020 and electronically signed by the administrator and patient #3. This document stated "... IMPORTANT: If you have any further questions or in the event of a complaint, please contact our Administrator: (phone number for home care agency B in Arizona)...." During an interview on 3/23/2021 at 4:18 p.m., the administrator was queried as to whose phone number was (623) 535 - 9607, to which he stated "Ok."

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was updated and revised at discharge in 1 of 2 closed records reviewed. (#6) The findings include: Review of an undated agency policy titled "Discharge Criteria and Process" stated, "... An update to the comprehensive assessment, including required OASIS data elements, will be completed, as required by regulation ... All discharge paperwork will be due in the office within 72 hours of the discharge date. This will include the discharge order, discharge summary, plan of care, medication profile and OASIS...." Review of an agency document on 3/11/2021 titled "Transfer-Discharge From Home Health Services" dated 3/11/2021 evidenced patient #6 was discharged on 3/11/2021. Clinical record review on 3/15/2021 and 3/22/2021 for patient #6, start of care 9/16/2020, failed to evidence the comprehensive assessment was updated at the time of discharge. During an interview on 3/22/2021 at 3:19 p.m., the administrator indicated there was not an updated comprehensive assessment at the time of discharge. The administrator indicated the patient was a non-visit discharge.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure revision of the plan of care to include updated care plan goals and the patient's progress, in 2 of 4 clinical records reviewed receiving skilled services. (#1, #4) The findings include: 1. The undated agency policy, retrieved 3/23/21, titled "Care Planning Process" Policy No. [number] 2-018.1 stated "Purpose To provide clinical direction to clinicians providing direct patient care. ... Procedure 3. Based on the assessment and conclusions, the plan of care will include, but not be limited to: ... D. Reasonable, measurable, and individualized goals and outcomes identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care ... F. Actions to be taken to meet the patient goals ... 4. The care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals. ... 7. The plan of care will be revised frequently as deemed necessary by the clinician, based on the ongoing assessments of the patient. Revision dates will be noted on the plan of care. ... 9. Changes in the plan of care will be noted with the following documentation: A. Assessment B. Plan of care with clinical outcome goals ... 13. Services to be provided will be based on the prioritized needs of the patient. Each patient will be monitored his/her response to care or services provided against established patient goals and patient outcomes to determine if goals have been achieved. 14. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing assessments, and analysis of patient response to care against goals and outcomes...." 2. Clinical record review for patient #1, start of care 10/29/2020, certification period 2/26/21 - 4/26/21, evidenced an agency document titled " Home Health Certification And Plan Of Care" dated and electronically signed by employee A on 02/22/2021. This document had a section subtitled "22. Goals/Rehabilitation Potential/Discharge Plans/Referral Plan/Other Notes" which stated "... Patient / Caregiver Verbalize / Demonstrate Ability To Care For Patient Throughout This Episode Of Care. Patient Will Have No S/S [signs/symptoms] Infection During This Episode Of Care. Patient Will Demonstrate Ability To Prevent Pressure Ulcers By The End Of This Episode Of Care. Patient And Caregiver Will Demonstrate Ability To Care For Urostomy By The End Of This Episode Of Care. Patient Will Have Return Of Normal Bowel Pattern By End Of This Episode Of Care...." Clinical record review evidenced an agency document titled "Skilled Nursing Visit Note" dated and electronically signed by employee B on 2/26/21. This document had an area subtitled "Care Plan Update" which stated "... Patient Centered Goals: Patient's level of ability to perform activities of daily living will not deteriorate from the baseline throughout 9 weeks. ... Interventions: Skilled Nurse to assess the patient's capacity to perform activities of daily living to identify the baseline and to identify the level of assistance the patient needs. ... Progress Towards Goals: Ongoing ... Patient Centered Goals: Patient/Caregiver will verbalize understanding of the methods to prevent falls within 1 week. ... Interventions: Skilled Nurse to instruct the patient/caregiver to contact 911/MD [medical doctor]/Skilled Nurse immediately went a fall incident occurs. Status: Ongoing ... Patient Centered Goals: Patient will be free from accidents, falls, or injuries throughout 9 weeks. ... Interventions: Skilled Nurse to evaluate the patient's environment for hazards which may cause accidents or injuries such as loose carpets/rugs, items that may block the pathway, slippery floor, beds without rails, dim lighting, unstable stairs, and spilled liquids on the floor. Status: Ongoing ... Patient Centered Goals: Patient will be able to wheel self or be wheeled by caregiver safely without incidence of falls throughout 9 weeks. ... Interventions: Skilled Nurse to instruct patient/caregiver to keep pathways clear, remove clutter, keep environment well lit and observe safety measures and precautions when using wheelchair to prevent falls. Status: Ongoing ... Patient Centered Goals: Patient/caregiver will be able to verbalize understanding and will be able to demonstrate safety measures and precautions on the use of wheelchair within 2 weeks. ... Interventions: Skilled Nurse to educate patient/caregiver on safety measures and precautions on the use of wheelchair brakes and adjust or lift foot rests during transfers or before getting out or into the wheelchair. Status: Ongoing ... Patient Centered Goals: Patient engages in desired activities without an increase in pain level within 4 weeks. ... Interventions: Skilled Nurse to provide the patient and family with adequate information about chronic pain and options available for pain management. Status: Ongoing Progress Towards Goals: Ongoing...." Clinical record review failed to evidence the plan of care was updated to include the updated care plan goals as evidenced on the skilled nurse visit note. During an interview on 3/22/21 at 2:03 p.m., the clinical manager indicated she had noticed the goals were different before and she didn't understand that. 3. Clinical record review for patient #4, start of care 07/06/2020, evidenced agency documents titled "Skilled Nursing Visit Notes" dated 01/08/2021, 01/13/2021, 01/20/2021, 01/27/2021, 02/03/2021, 02/10/2021, 02/17/2021 and 02/22/2021, all electronically signed by the clinical manager. These skilled nurse visit noted indicated the patient had a diffuse rash with blisters. During an interview on 3/23/2021 at 4:34 p.m., the clinical manager indicated the patient was on doxycycline (an antibiotic) for the skin infection. Clinical record review of an agency document titled "Home Health Certification And Plan Of Care" for certification period 01/02/2021 - 03/02/2021, failed to evidence a revision to include the patient's diffuse skin rash an antibiotic for skin infection. During an interview on 3/23/2021 at 4:40 p.m., the clinical manager indicated the plan of care should have been revised, but she didn't know if it had because employee A/physical therapist/administrator does the plan of cares.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians involved in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, the home health agency failed to ensure all physicians ordering care for the agency patient were communicated and approved by the primary care physician in 1 of 1 clinical records with more than one physician. (#3) The findings include: An undated agency policy, retrieved on 03/23/2021, titled "Physician Participation In Plan Of Care" Policy No. [number] 2.019.1 stated "... 8. Orders will be reviewed and revised by the patient's physician (or other authorized licensed independent practitioner) based on: A. Changes in the care or service being provided ... E. Changes in diagnoses or treatment, including procedures, medications and equipment ... 12. If a patient is under the care of more than one (1) physician, the nurse will be responsible to the first referring physician. All other physicians should be made aware of the services being provided to the patient. The referring physician will be informed of the involvement of other medial clinicians...." Clinical record review for patient #3, start of care 02/15/2020, evidenced an agency document titled "Home Health Certification And Plan Of Care" for certification period 03/11/2021 - 05/09/2021, dated and electronically signed by the administrator on 3/11/2021. This plan of care indicated the patient's physician was Physician E. There was no evidence on the plan of care or in the clinical record the authorization or acknowledgement of acceptance of any other physician orders. Clinical record review evidenced an agency document titled "Physician Order" dated 03/11/2021 and electronically signed by the administrator. This document indicated the physician was Physician F and stated "... Prescribing Physician : [name of Physician E] ... Type of Order: Referred for Admission ... Order Date: 03/11/2021 Order Time: 08:20 AM Reasons/Notes: Please admit for PT [physical therapy] Only for wound debridement ... Orders: PT for assessment and treatment for Debridement and Improvement in wheelchair mobility and tolerance ... Goals: For skilled care and management with aide supervision every 15 days as required by skilled care...." This document had a check mark in a box next to "Order Read Back And Verified With Physician" This document had Physician F's name in the signature box. 17-14-1(a)(1)(G)

Program scope CFR(s): 484.65(a)(1),(2) Standard: Program scope. (1) The program must at least be capable of showing measurable improvement in indicators for which there is evidence that improvement in those indicators will improve health outcomes, patient safety, and quality of care. (2) The HHA must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that enable the HHA to assess processes of care, HHA services, and operations. This STANDARD is not met as evidenced by: Based on record review and interview, the home health agency failed to measure, analyze and track quality indicators and other aspects of performance that enable the agency to assess processes of care, agency services and operations. The findings include: Review of an undated agency policy titled "Organizational Planning" stated, "... The leaders plan and monitor the organization's care and services to be consistent with its mission and patient needs. The planning process includes: ... The data needed to measure the performance of the processes and outcomes of care and services ... Results of organization performance improvement activities ...." Request was made to the administrator to review the quality assurance and performance improvement (QAPI) program on 3/12/2021 at 2:35 p.m. The administrator indicated the binder labeled "QAPI" on the administrator's desk was the old QAPI program. The administrator searched his computer for QAPI documents which he indicated returned results for QAPI documents dated November 2019. When queried if there was a QAPI program for review, the administrator stated, "Not at this time, but I will update it." When queried what the administrator would update, the administrator stated, "Just look at the old one, and I'll update it." Review of the binder labeled "QAPI" on 3/12/2021 indicated the most recent quality indicator was from 2019. Review failed to evidence the agency measured, analyzed and tracked quality indicators and other aspects of performance that enabled the agency to assess processes of care, agency services and operations since 2019. During an interview on 3/12/2021 at 3:00 p.m., the administrator indicated the consultant informed him the QAPI information was in the electronic medical record. The administrator indicated he was unable to print the document titled "QAPI Data" due to no toner in the printer. Review of agency document titled "QAPI Data" on 3/12/2021 on the administrator's computer screen evidenced the document was generated on 3/12/2021. Review failed to evidence the agency measured, analyzed and tracked quality indicators and other aspects of performance that enabled the agency to assess processes of care, agency services and operations. During an interview on 3/12/2021 at 3:15 p.m., the administrator indicated there was nothing more to review for the QAPI program. No further documentation was provided. 17-12-2(a)

High risk, high volume, or problem-prone area CFR(s): 484.65(c)(1)(i) (i) Focus on high risk, high volume, or problem-prone areas; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the performance improvement activities focused on high risk, high volume, or problem-prone areas. The findings include: Review of an undated agency policy titled "Organizational Planning" stated, "... The leaders plan and monitor the organization's care and services to be consistent with its mission and patient needs. The planning process includes: ... The data needed to measure the performance of the processes and outcomes of care and services ... Results of organization performance improvement activities ...." Review of the quality assessment and performance improvement (QAPI) program on 3/12/2021 failed to evidence performance improvement activities which focused on high risk, high volume or problem-prone areas. During an interview on 3/12/2021 at 3:15 p.m., the administrator indicated there was nothing more to review for the QAPI program. No further documentation was provided.

Incidence, prevalence, severity of problems CFR(s): 484.65(c)(1)(ii) (ii) Consider incidence, prevalence, and severity of problems in those areas; and This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the performance improvement activities considered incidence, prevalence and severity of problems. The findings include: Review of an undated agency policy titled "Organizational Planning" stated, "... The leaders plan and monitor the organization's care and services to be consistent with its mission and patient needs. The planning process includes: ... The data needed to measure the performance of the processes and outcomes of care and services ... Results of organization performance improvement activities ...." Review of the quality assessment and performance improvement (QAPI) program on 3/12/2021 failed to evidence performance improvement activities which considered incidence, prevalence and severity of problems. During an interview on 3/12/2021 at 3:15 p.m., the administrator indicated there was nothing more to review for the QAPI program. No further documentation was provided.

Improvements are sustained CFR(s): 484.65(c)(3) The HHA must take actions aimed at performance improvement, and, after implementing those actions, the HHA must measure its success and track performance to ensure that improvements are sustained. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to take actions aimed at performance improvement, and after implementing those actions, the agency must measure its success and track performance to ensure improvements are sustained. The findings include: Review of an undated agency policy titled "Organizational Planning" stated, "... The leaders plan and monitor the organization's care and services to be consistent with its mission and patient needs. The planning process includes: ... The data needed to measure the performance of the processes and outcomes of care and services ... Results of organization performance improvement activities ...." Request was made to the administrator to review the quality assurance and performance improvement (QAPI) program on 3/12/2021 at 2:35 p.m. The administrator indicated the binder labeled "QAPI" on the administrator's desk was the old QAPI program. The administrator searched his computer for QAPI documents which he indicated returned results for QAPI documents dated November 2019. When queried if there was a QAPI program for review, the administrator stated, "Not at this time, but I will update it." When queried what the administrator would update, the administrator stated, "Just look at the old one, and I'll update it." Review of the binder labeled "QAPI" on 3/12/2021 indicated the most recent quality indicator was from 2019. Review failed to evidence the agency took actions since 2019 aimed at performance improvement and measure the success and track performance to ensure improvements were sustained. During an interview on 3/12/2021 at 3:00 p.m., the administrator indicated the consultant informed him the QAPI information was in the electronic medical record. The administrator indicated he was unable to print the document titled "QAPI Data" due to no toner in the printer. Review of agency document titled "QAPI Data" on 3/12/2021 on the administrator's computer screen evidenced the document was generated on 3/12/2021. Review failed to evidence the agency took actions aimed at performance improvement and measure the success and track performance to ensure improvements were sustained. During an interview on 3/12/2021 at 3:15 p.m., the administrator indicated there was nothing more to review for the QAPI program. No further documentation was provided. 17-12-2(a)

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 a performance improvement project that reflected the scope, severity and past performance of the agency's services and operations and failed to document the quality improvement project which was conducted, the reasons for conducting the project and the measurable progress achieved on the project. The findings include: Review of an undated agency policy titled "Organizational Planning" stated, "... First Choice Home Health Services Inc's leaders are responsible for developing and implementing an effective, systematic, organization-wide planning process that includes: ... Implementing activities that focus on the following: ... Improving patient safety and health care quality ... The leaders plan and monitor the organization's care and services to be consistent with its mission and patient needs. The planning process includes: ... The data needed to measure the performance of the processes and outcomes of care and services ... Results of organization performance improvement activities ...." During an interview at the entrance conference on 3/11/2021 at 10:30 a.m., the administrator indicated the agency's performance project was the home health aide training and competency. Request was made to the administrator to review the quality assurance and performance improvement (QAPI) program on 3/12/2021 at 2:35 p.m. The administrator indicated the binder labeled "QAPI" on the administrator's desk was the old QAPI program. The administrator searched his computer for QAPI documents which he indicated returned results for QAPI documents dated November 2019. When queried if there was a QAPI program for review, the administrator stated, "Not at this time, but I will update it." When queried what the administrator would update, the administrator stated, "Just look at the old one, and I'll update it." Review of the binder labeled "QAPI" on 3/12/2021 failed to evidence QAPI data since 2019. During an interview on 3/12/2021 at 3:00 p.m., the administrator indicated the consultant informed him the QAPI information was in the electronic medical record. The administrator indicated he was unable to print the document titled "QAPI Data" due to no toner in the printer. The administrator indicated the performance improvement projects were home heath aide training and competency and infection surveillance. The administrator indicated there was no infection surveillance plan to review because the information was in his head. Review of an agency document titled "QAPI Data" on 3/12/2021 on the administrator's computer screen evidenced the document was generated on 3/12/2021. Review failed to evidence a performance improvement project that reflected the scope, severity and past performance of the agency's services and operations and failed to document the quality improvement project which was conducted, the reasons for conducting the project and the measurable progress achieved on the project. During an interview on 3/12/2021 at 3:15 p.m., the administrator indicated there was nothing more to review for the QAPI program. No further documentation was provided.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the skilled nurse and physical therapist assistant followed the medical plan of care in 2 of 4 clinical records reviewed with skilled nursing services. (#4, #5) The findings include: 1. The undated agency policy, retrieved 3/23/21, titled "Monitoring Patient's Response/Reporting To Physician" Policy No. [number] 2-029.1 stated "Purpose To provide guidelines for monitoring the patient's conditions, response to care and for reporting to the patient's physician. Policy Clinicians will monitor, document, and report the patient's response to care and treatment provided on each home visit. ... Procedure 1. During each home visit, the clinician will monitor the patient's response to care against the established goals, including, but not limited to: A. Care interventions and treatments B. Medications C. Teaching ... 3. The patient's physician will be contacted on the same day when any of the following occur: ... F. When there is any problem implementing the plan of care...." 2. An undated agency policy, retrieved 3/23/21, titled "Care Planning Process" Policy No. 2-018.1 stated "Purpose To provide clinical direction to clinicians providing direct patient care. ... Procedure ... 14. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing assessments, and analysis of patient response to care against goals and outcomes...." 3. An undated agency policy, retrieved on 3/23/21, titled "Ongoing Assessments" Policy No. 2-008.1 stated "Purpose To provide guidelines for assessments of patients during ongoing care. ... Procedure 1. During each home visit, the clinician or other discipline will re-evaluate the patient according to the problems identified during the initial visit and subsequent visits. 2. Using the standards of care identified by the organization, the clinician will reassess the patient (as appropriate) for: A. Blood pressure, pulse, respirations, temperature ... 5. Based on each reassessment, the plan of care-including problems, needs, goals, and outcomes-will be reviewed and revised by the clinician...." 4. Clinical record review for patient #4, start of care 07/06/2020, evidenced an agency document titled "Home Health Certification And Plan Of Care" for certification period 01/02/2021 - 03/02/2021, with a principal diagnosis of multiple sclerosis and other pertinent diagnoses as, but not limited to, hypertensive heart disease without heart failure and essential (primary) hypertension, dated and electronically signed by the clinical manager on 12/30/2020. This plan of care had an area subtitled "21. Orders for Discipline and Treatments (Specific Amount/Frequency/Duration)" which stated "... Skilled Nurse to educate patient/caregiver on prescribed hypertensive medications along with their rationale, dosage, expected and adverse side effects, and idiosyncrasies. Skilled Nurse to educate patient/caregiver on the disease process of hypertension and how it affects the cardiovascular system function, kidneys and brain; that hypertension is a lifelong medication condition and that adherence to treatment plan is necessary even when patient is feeling well. ... Parameter: Systolic BP [blood pressure] 180.00 mmhg [millimeter mercury] Notify MD [medical doctor] Diastolic BP 100.00 mmhg Notify MD ... Pulse Rate 110.00 /min [minute] Notify MD...." Clinical record review evidenced an agency document titled "Skilled Nursing Visit Note" dated 02/22/2021 and electronically signed by the clinical manager. The skilled nursing note failed to evidence the patient's pulse or blood pressure was assessed. The skilled nurse failed to follow the medical plan of care. During an interview on 3/23/21 at 4:31 p.m., the clinical manager indicated the pulse and blood pressure should have been assessed and that she was surprised the electronic medical record let her sign the skilled nursing visit note without that information. Clinical record review evidenced an agency document titled "Home Health Certification And Plan Of Care" for certification period 01/02/2021 - 03/02/2021, dated and signed by the clinical manager on 12/30/2020. This plan of care had an area subtitled "21. Orders for Discipline and Treatments (Specific Amount/Frequency/Duration)" which stated "... Physical Therapy - Frequency and Duration: 1W8 [one time weekly for 8 weeks] ... Progressive Therapeutic Exercise Transfer Training Body Mechanics/Posture Training of assistance Teach bed mobility skills Wheelchair Training PT/PTA [physical therapist/physical therapy assistant] to provide transfer training from various chair heights in order to improve safety and independence with all sit-stand transfers. PT/PTA to provide education/intervention for increased performance/independence level in adls [activities of daily living] with DME [durable medical equipment] as pt [patient] is bed hound [sic] and continues to require maximum assist due to being bed bound and on wheel chair. Unable to complete her daily activities...." Clinical record review evidenced an agency document titled "Physical Therapy Progress Visit" dated and electronically signed by PTA [physical therapy assistant] L on 1/15/2021. This document indicated the PTA performed vital signs, rated pain, did supine bilateral upper and lower extremity exercises x 20 repetitions and bed mobility rolling side to side. This document also indicated the patient was taught the home exercise program. The PTA failed to follow the medical plan of care. Clinical record review evidenced an agency document titled "Physical Therapy Progress Visit" dated and electronically signed by PTA L on 01/22/2021. This document indicated the PTA performed vital signs, rated pain, did supine bilateral upper and lower extremity exercises x 20 repetitions and provided teaching for the home exercise program. The PTA failed to follow the medical plan of care. Clinical record review evidenced an agency document titled "Physical Therapy Progress Visit" dated and electronically signed by PTA L on 02/05/2021. This document indicated PTA L performed vital signs, rated pain, did bilateral upper and lower extremity exercises in supine position x 10 repetitions and taught the home exercise program. The PTA failed to follow the medical plan of care. Clinical record review evidenced an agency document titled "Physical Therapy Progress Visit" dated and electronically signed by PTA L on 02/19/2021. This document indicated PTA L performed vital signs, assessed pain, did supine bilateral lower extremity exercises x 20 repetitions and provided home exercise program teaching. The PTA failed to follow the medical plan of care. Clinical record review for certification period 01/02/2021 - 03/02/2021, principal diagnosis of multiple sclerosis, failed to evidence the patient received physical therapy services as ordered in the medical plan of care the weeks of 12/30/2020 - 01/02/2021, 01/24/2021 - 01/30/2021, and 02/21/2021 - 02/27/2021 and there failed to be evidence of any missed visit notes for these weeks in the clinical record. The physical therapist failed to follow the medical plan of care.5. Clinical record review on 3/22/2021 for patient #5, start of care 12/18/19, evidenced an agency document titled "Home Health Certification and Plan of Care" for certification period 2/10/2021 - 4/10/2021. Review indicated the patient was to receive skilled nursing services once a week for 8 weeks to include, but not limited to, the skilled nurse to assess the patient's description, level and location of pain. Review of agency documents titled "Skilled Nursing Visit Note", dated 2/24/2021 and 3/3/2021 and electronically signed by RN B, which indicated the patient had pain to the left hip daily. Review failed to evidence the skilled nurse assessed the level of pain as directed in the plan of care. During an interview on 3/22/2021 at 3:36 p.m., the clinical manager indicated the skilled nurse should have assessed the patient's pain level. 17-14-1(a)(1)(H)

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure the clinician who performed the comprehensive assessment / reassessment of the patient developed the patient's plan of care and / or completed the reassessment clinical document, in 2 of 4 clinical records reviewed receiving skilled services. (#1, #4) The findings include: 1. The undated agency policy, retrieved 3/23/21, titled "Entries Into The Clinical Record" Policy No. [number] 5-006.1 stated "Purpose To define personnel who have authority to make entries into the clinical record and to provide guidelines for valid data collection. Policy Home health personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. ... 7. The clinical note will include: A. Care that was provided B. Treatment and/or invasive procedures performed C. Patient response to treatment and/or procedures D. The date the service was provided (month, day, year) E. Signature of clinician and his/her credentials...." 2. Clinical record review for patient #1, start of care 10/29/2020, certification period 2/26/21 - 4/26/21, evidenced an agency document titled "Oasis D1-Recertification" dated and electronically signed by the clinical manager on 2/22/21. This document indicated the clinical manager did the assessment from 3:00 p.m. - 4:00 p.m. Clinical record review of this document evidenced the clinical manager performed care coordination with the skilled nurse and the physician following the comprehensive recertification assessment. Clinical record review evidenced an agency document titled "Home Health Certification And Plan Of Care" for certification period 2/26/21 - 4/26/21. This plan of care indicated it was created by the administrator/physical therapist/employee A and electronically signed on 2/22/21. Record review failed to evidence the administrator was involved in the comprehensive assessment of patient #1 in order to develop an accurate plan of care. The clinician who performed the comprehensive assessment in conjunction with the primary care physician failed to establish the patient's plan of care. During an interview on 3/22/21 at 1:45 p.m., the administrator indicated he reviewed the plan of care, but the clinical manager created the plan of care. The administrator indicated he electronically signed the document just to get it to the physician. During an interview on 3/22/21 at 1:51 p.m., the administrator indicated he reviews the plan of care for completion and not content. He indicated he contacted the clinical manager for content. Then the administrator stated "I think we need to change our system." 3. Clinical record review for patient #4, start of care 07/06/2020, principal diagnosis of multiple sclerosis, evidenced an agency document titled Physical Therapy Reassessment" dated and signed by PT [physical therapist] M on 01/29/2021. This physical therapy reassessment document failed to be completed and reflect the patient's current status from the assessment on 01/29/2021. During an interview on 3/23/2021 at 5:29 p.m., the administrator indicated they do not have this reassessment. 17-14-1(a)(1)(E) 17-14-1(c)(5)

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician; (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 record review, the home health agency failed to ensure the home health aides followed the aide care plan established by the registered nurse / licensed professional and performed tasks consistent with the aide care plan and tasks in which they were competencied for in 4 of 4 clinical records reviewed with home health aide services. (#2, #3, #4, #6) The findings include: 1. The undated agency policy, retrieved 3/23/21, titled "Home Health Aide Plan Of Care" Policy No. [number] 2-023.1 stated "Purpose To define the process for the development and use of the home health aide plan of care. Policy Each patient receiving home health aide services will have an individualized plan developed and utilized to direct care performed by the assigned aide. Procedure ... 2. The home health aide plan of care will be individualized to the specific patient and will include at least: A. Type of services/procedures to be provided, such as hands on personal care, the performance of simple procedures as an extension of therapy or nursing services, assistance in ambulation or exercises, and assistance in administering medication ordinarily self-administered. ... 8. The Case Manager or other appropriate clinician will directly supervise the home health aide at least every 14 days to ensure care is provided according to plan...." 2. Clinical record review for patient #2, start of care 11/6/2020, certification period 3/6/2021 - 5/4/2021, evidenced an agency document titled "Home Health Aide Care Plan" dated and signed by employee A (physical therapist) on 1/5/21. This document retrieved on 3/12/21 failed to evidence any frequency for the tasks the home health aide was to complete. This document indicated the home health aide was to perform a bath, shampoo, comb hair, shave, oral care, foot care, nail care/cut nails, lotion/rub, assist with dressing, skin care/check pressure area, incontinent care B&B [bowel and bladder], linen change, perineal care, light housekeeping, make bed, light laundry, turn/reposition, assist with ambulation, assist with transfer, offer fluids, prepare and serve diet, assist with feeding, range of motion exercises, and medication reminder. Clinical record review evidenced an agency document titled "Home Health Aide Visit" dated and electronically signed by home health aide C on 2/22/2021. This home health aide visit note failed to evidence the home health aide provided the patient with a shave as ordered on the aide care plan. On 3/22/21 at 2:46 p.m., the administrator and clinical manager was informed of this concern and remained silent. 3. Clinical record review for patient #3, start of care 02/15/2020, evidenced an agency document titled "Home Health Aide Care Plan" dated and electronically signed by the administrator on 03/11/2021. This aide care plan indicated the home health aide was to provide a bath, comb hair, shave, oral care, foot care, nail care / cut nails, lotion/ rub, assist with dressing, skin care/check pressure areas, incontinent care of bowel and bladder, linen change, perineal care, light housekeeping, make bed, light laundry, grocery shopping, turn/reposition, encourage fluids, prepare and serve diet, assist with feeding, range of motion exercised, and medication reminder. No other tasks were evidenced on the aide care plan. Clinical record review evidenced an agency document titled "Home Health Certification And Plan Of Care" for certification period 03/11/2021 - 05/09/2021, dated and electronically signed by the administrator on 03/11/2021. This document indicated the patient had a principal diagnosis of pressure ulcer of right buttock, stage 2. This plan of care had an area subtitled "21. Orders for Discipline and Treatments (Specific Amount/Frequency/Duration)" which stated "... Wound care orders: Cleanse wound with wound cleanser/ns [normal saline] pat dry, apply santyl as needed and cover with a clean dry dressing daily and PRN [as needed] for soilage...." During an interview on 03/12/2021 at 11:35 a.m., the administrator indicated he did not visit patient #2 on Thursday, 03/11/2021. He indicated he spoke with the home health aide and she told him the wound was okay, and this is why he didn't go yesterday. Personnel record review of home health aide D, failed to evidence the home health aide was competent to assess wounds. 4. Clinical record review for patient #4, start of care 07/06/2020, evidenced an agency document titled "Oasis D1 - Start Of Care" dated and electronically signed by the clinical manager on 03/11/2021. This document had an area subtitled "Integumentary Status" which indicated the patient had a stage 2 pressure ulcer to her right buttocks which was cleansed, measured and a moisture barrier applied by the skilled nurse. During an interview on 3/23/2021 at 4:27 p.m., the clinical manager indicated she performed wound care weekly and the home health aide performed wound care after the patient's bath and after every bowel movement.5. Clinical record review on 3/22/2021 for patient #6, start of care 9/16/2020, evidenced an agency document titled "Home Health Aide Care Plan", electronically signed by physical therapist (PT) A and dated 1/14/2021. Review of the care plan indicated the home health aide was to shampoo and comb the patient's hair; provide oral, foot, nail and skin care; apply lotion to the patient and assist with dressing the patient. Review of agency documents titled "Home Health Aide Visit", electronically signed by HHA O, failed to evidence the HHA provided oral care and foot care and shampooed and combed the patient's hair on 2/4/2021, 2/5/2021, 2/8/2021, 2/10/2021, 2/11/2021 and 2/12/2021. Review failed to evidence HHA O provided nail care and skin care on 2/4/2021, 2/5/2021, 2/10/2021, 2/11/2021 and 2/12/2021. Review failed to evidence HHA O applied lotion to the patient and assisted the patient with dressing on 2/4/2021, 2/5/2021 and 2/8/2021. During an interview on 3/22/2021 at 3:08 p.m., the administrator indicated the home health aide was to provide services Monday through Friday from 8:00 a.m. to 4 p.m. The administrator indicated the HHA should have provided the tasks as directed in the HHA care plan at every visit. The administrator indicated the HHA should document if the patient refused any tasks. 17-3-2(b)

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on observation, record review and interview, the home health agency failed to ensure all clinical records and patient information was safeguarded from unauthorized use. The findings include: The undated agency policy, retrieved on 3/23/21, titled "Confidentiality Of Informant" Policy No. [number] 1-015.1 stated "Purpose To ensure the patient's right to privacy is protected by following the policies and procedures regarding confidentiality and use and disclosure of protected health information (PHI), as necessary. Policy First Choice Home Health Services Inc and its personnel will maintain as confidential all patient-protected health information. Protected health information will be used and disclosed in accordance with the organization's policies and procedures. ... Procedure 1. During the orientation process, this Confidentiality Policy will be reviewed by organization personnel. 2. All organization personnel will be required to sign a Confidentiality Agreement at the time of hire. ... 11. The organization respects the safety and security of patients and their property. 12. All clinical records will be kept in a locked cabinet/room when not being utilized. The Clinical Supervisor or designee will be responsible for the key. No unauthorized individual will be allowed access to clinical records. 13. The following patient information will be secured after business hours: A. Clinical records B. Field clinical records C. Patient intake information D. Minutes of patient care meetings E. Performance improvement data F. Clinical notes prior to filing in clinical record...." The undated agency policy, retrieved on 3/23/21, titled "Privacy Of PHI [protected health information]" Policy No. [number] 1-024.1 stated "Purpose To establish a procedure to prevent, detect, contain and correct privacy violations involving protected health information. Policy The organization will identify risks and safeguard protected health information against loss, destruction, tampering, or unauthorized use. Procedure ... 3. First Choice Home Health Services Inc will train all employees and volunteers on the privacy policies and procedures as necessary and appropriate for them to carry out their functions. ... 5. First Choice Home Health Services Inc will implement security measures sufficient to reduce risks and vulnerabilities to a reasonable and appropriate level to comply with HIPAA security standards...." Upon entrance to First Choice Home Health Services on 3/11/2021 at 10:01 a.m., a female was observed to be in the home health agency office alone and sitting at a desk full of papers and agency manuals. This desk was later identified to be the administrator's desk. The female stated her name and indicated she was just there alone to fill out an employment application with the home health agency. The female indicated an agency home health aide had unlocked the office and let her into the building. The home health aide was not present in the home health agency office upon entrance. During an interview on 3/11/2021 at 2:25 p.m., the administrator indicated the female that had been in the office upon entrance was going to be a newly hired nurse. 17-15-1(c)