Every finding on record at Focus Home Health Care, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 7/11/24. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 7/11/24. Standard level deficiencies cited. Abbreviations: AM = morning PM = afternoon/evening Pt./Pts. = Patient/Patients OT = Occupational Therapist PT = Physical Therapist SN = Skilled Nurse ST = Speech Therapist SOC = Start of Care MSW = Medical Social Worker MD = Medical Doctor OASIS = Outcome and Assessment Information Set RN = Registered Nurse CNA = Certified Nursing Assistance HHA = Home Health Aide

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report and staff interviews, it was determined that in 92 of 658 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Finding include: 1. The Error Summary report for 4/2023 to 3/2024, was reviewed on 7/11/24. The report included error # -3330 for 92 of 658 late submissions, which was 13.98% of the OASIS reports submitted late, more than 30 days after the M0090. 2. During an interview with the Administrator and Alternate Agency Supervisor on 7/11/24 at 11:00 AM, the administrative team confirmed that the error occurred.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record reviews and staff interviews, it was determined the Agency failed to ensure an RN performed the initial assessment within 48 hours of the Physician referral for Home Health Care services. This was found in 2 of 7 (Pts. #4 and 6) clinical records reviewed. 1. Pt. #4 was admitted to Home Health Services on 4/29/24 with diagnosis of Cellulitis of Left Lower Limb. The clinical record was reviewed on 7/9/24. The Face-to Face form signed by the A/GNP (Adult Gerontology Nurse Practitioner) on 4/25/24 and received by Agency on 4/26/24 required: "Skilled Nursing wound care BLE (Bilateral Leg Extremity) and PT/OT evaluation and treatment.” The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 7/11/24, the record lacked documentation the Agency initiated service within the required time frame. 2. Pt. #2 was admitted to Home Health Services on 7/20/23 with the diagnosis of Bilateral Primary Osteoarthritis of Hip. The clinical record was reviewed on 7/9/24. The Face-to Face form signed by the Physician on 6/28/23 and received by Agency on 7/17/23 required: "SN services, PT to improve patient’s gait for safety and mobility, MSW evaluation for homemaker and CNA/HHA for bathing. The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 7/11/24, the record lacked documentation the Agency initiated service within the required time frame. 3. During an interview with the Agency Supervisor and Alternate Agency Supervisor, on 7/10/24 at 12:30 PM, the administrative team confirmed the initial assessment visits were conducted, after 48 hours of the Face to Face or referral date.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, policy review and staff interviews, it was determined for 1 of 7 (Pt. #5) Pts., the Agency failed to ensure Plans of Care included all the requirements. Findings include: 1. Pt. #5 was admitted for home health services on 4/25/24 with the primary diagnosis of Pressure Ulcer of the Right Buttock. The clinical record was reviewed on 7/10/24. The SOC comprehensive assessment and all the SN notes contained documentation that Pt. #5 uses a urinary catheter related to the diagnosis of urinary retention. Pt. #5’s Plans of Care for the certification periods of 4/25/24 to 6/23/24 and 6/24/24 to 8/22/24 lacked documentation of the use of a urethral catheter and lacked the procedure, the equipment, and supplies used for its care. 2. The policy titled “Care Plans” was reviewed on 7/10/24 and required: “Policy: Each client will have a care plan on file that addresses their identified needs and the (Agency’s) plan to respond to those needs…Purpose: …To provide updated, coordinated document that reflects the current home care services.” 3. During an interview conducted with the Agency Supervisor and the Alternate Agency Supervisor on 7/10/24 at 11:00 AM, the above finding was confirmed.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review, policy review and staff interviews, it was determined for 1 of 3 (Pt. #5) clinical records reviewed receiving wound care, the Agency failed to ensure care and/or services were provided in conformance with the orders of the physician and as indicated in the Plan of Care. Findings include: 1. Pt. #5 was admitted to home health services on 4/25/24 with the primary diagnosis of Pressure Ulcer of The Right Buttock Stage 2 and other diagnosis of, but not limited to, Pressure Ulcer of The Left Buttock Stage 2, Hypertensive Heart Disease with Heart Failure and Encounter for Fitting and Adjustment of Urinary Device. The clinical record was reviewed on 7/10/24. The face-to-face document dated 4/25/24 which contained physician orders, included the following documentation: “Urinary Retention: Continue with monthly changes 14 French.” The SN notes dated 4/29/24, 5/27/24, 6/3/24 and 7/3/24 contained documentation that the urinary catheter was changed by the SN using a French 16 size urinary catheter. The clinical record lacked documentation of a physician order indicating a change in the size of Pt. #5's urinary catheter. The referral document dated 4/18/24 also included the following: “Please review for PT/OT...” The clinical record lacked documentation of an OT evaluation or visit. Pt. #5’s Plan of Care effective 6/24/25 required: “SN to measure wound once a week and report to MD wound progress as needed.” The SOC comprehensive assessment and SN notes from 5/6/24 to 7/3/24 lacked documentation of wound measurements. The same Plan of Care required: “SN to monitor and report weight gain of 2 pound in a day or 5 pounds in 7 days. “ The SOC comprehensive assessment and SN notes from 5/6/24 to 7/3/24 lacked documentation of the monitoring of Pt. #5’s weight. 2. The policy titled, “Wound Care and Management Policy” was reviewed on 7/10/24 and required, “2. Skilled Nurse will document wound assessment in the Skilled Nursing visit at least once a week…Documentation may include the following: …Measurement (Length, Width, Depth)." 3. The policy titled, “Physician Orders” was reviewed on 7/10/24 and required. “All medications, treatments, and services provided to clients must be ordered by a physician or authorized practitioner…All medications and treatments that are part of the client’s plan of care must be ordered by the physician." 4. During an interview conducted with the Agency Supervisor and the Alternate Agency Supervisor on 7/10/24 at 11:00 AM, it was stated that physician orders and orders on the care plan should be followed. During the same interview, the above findings were confirmed.

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: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update its Emergency Plan and policies biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 6/14/21 at 10:15 AM. This plan was titled "Plan for Emergency Preparedness Policies and Procedures," and was dated November 16, 2017. The plan/policy lacked documentation it was reviewed/revised since November 2017. 2. During an interview with the Director of Nursing on 6/16/21 at 12:45 PM, the above finding was confirmed.

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: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Emergency Preparedness Plan was based on an updated facility and community risk assessment, utilizing an all hazards approach. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 6/14/21 at 10:15 AM. The plan included documentation Hazard Vulnerability Assessment but entries were incomplete and lacked the date it was completed. 2. During an interview with the Director of Nursing on 6/16/21 at 12:45 PM, the above finding was confirmed.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) [(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 (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the Emergency Plan included volunteers. This has the potential to affect all Pts. receiving services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 6/14/21 at 10:15 AM. The Plan did not include the use of volunteers. 2. During an interview with the Director of Nursing on 6/16/21 at 12:45 PM, the above finding was confirmed.

. Recertification survey was conducted. Standard level deficiencies cited. Focused Infection Control Survey was conducted. Abbreviations: AM= Morning PM= Afternoon Pt./Pts. = Patient/Patients SOC= Start of Care SN = Skilled Nurse RN= Registered Nurse POC = Plan of Care mg = milligrams

Written notice within 4 business days CFR(s): 484.50(a)(4) Provide written notice of the patient's rights and responsibilities under this rule and the HHA's transfer and discharge policies as set forth in paragraph (d) of this section to a patient-selected representative within 4 business days of the initial evaluation visit. This ELEMENT is not met as evidenced by: . A. Based on review of the Agency's Pt. admission folder, observations during home visits, clinical record review and staff interview, it was determined the Agency failed to ensure Pts. received a copy of the Agency's transfer and discharge policy. This was found in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed. Findings include: 1. The Agency Pt. admission folder provided by the Agency was reviewed on 6/14/21 at 11:00 AM. The folder lacked a copy of the Agency's transfer and discharge policy. 2. The following clinical records were reviewed from 6/14/21 to 6/15/21: Pt. #1. SOC 11/14/20 Pt. #2. SOC 3/8/21 Pt. #3. SOC 1/14/21 Pt. #4. SOC 3/3/21 Pt. #5. SOC 2/23/21 Pt. #6. SOC 1/18/21 Pt. #7. SOC 3/12/21 The clinical records lacked a copy of the Agency's transfer and discharge policy. 3. The following home visits were conducted on 6/15/21 from 10:00 AM to 3:30 PM: Pt. #1. SOC 11/14/20 Pt. #2. SOC 3/8/21 Pt. #3. SOC 1/14/21 During the home visits, the Pt. admission folders were reviewed. The folders lacked a copy of the Agency's transfer and discharge policy. 4. During an interview with Director of Nursing on 6/16/21 from 12:30 PM to 1:30 PM, it was indicated the same admission folder is given to all Pts. During the same interview, the above finding was confirmed.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure Pts. were informed of the frequency of visits provided by each discipline. This was found in 5 of 7 (Pts. #1, 2, 3, 4 and 5) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed on 6/14/21 at 2:45 PM to 6/15/21 at 4:30 PM: Pt. #1. SOC: 11/4/20. Pt. received SN, Physical Therapy and Home Health Aide services. Pt. #2. SOC: 3/8/21. Pt. received SN services. Pt. #3. SOC: 1/14/21. Pt. received SN services. Pt. #4. SOC: 3/3/21. Pt. received SN and Physical Therapy services. Pt. #5. SOC: 2/21/21. Pt. received SN services. The records lacked documentation that at the SOC, the Pt. or their representative participated or was notified of each discipline's frequency of visits, prior to providing Pt. care and services. 2. During an interview with the Director of Nursing, 6/16/21 from 12:30 PM to 1:30 PM, the Director of Nursing confirmed the Agency failed to ensure Pts. were informed, and/or participated determining the frequency of visits provided by each discipline.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure Pts. are advised of the extent of their financial liability for care, and/or services before care is initiated. This was found in 5 of 7 (Pts. #1, 3, 4, 5 and 6) clinical records reviewed. Findings include: 1. The clinical records of the Pts. listed below were reviewed on 6/14/21 at 2:45 PM to 6/15/21 at 4:30 PM. The records contained a form titled: "Consent For Home Care Services and Agreement" and contained the sections ''Medicare" and "Private Insurance." The sections lacked documentation indicating the Pt's financial responsibility. Pt. #1 SOC: 11/4/20 Pt. #3 SOC: 1/14/21 Pt. #4 SOC: 3/3/21 Pt. #5 SOC: 2/23/21 Pt. #6 SOC: 1/18/21 2. During an interview with the Director of Nursing on 6/16/21 at 12:30 PM to 1:30 PM, the above findings were confirmed.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: . A. Based on observations and interviews during home visits, review of clinical records and staff interview, it was determined the Agency failed to ensure the medications listed in the clinical record were complete and accurate. This was found in 2 of 7 (Pts. # 1 and 2) clinical records reviewed. Findings include: 1. Pt. #1. SOC 11/4/20. Principal Diagnosis: Bilateral Primary Osteoarthritis Of Knee. A home visit was conducted on 6/15/21 at 10:00 AM with the Home Health Aide. During the home visit, an interview was conducted with the Pt and the patient's medications were reviewed. The following medication bottles were found at patient's home: Sulindac 200 mg 1 tablet twice a day by mouth (bottle label date: 5/29/21), Benazepril/Hydrochlorothiazide 20 mg/25 mg 1 table once a day by mouth (bottle label date: 2/25/21). Pt. #1 stated, "Those are my medications ... (nurse) puts them in the pillbox for me ..." The clinical record was reviewed on 6/15/21 at 11:40 AM. The record contained a "Medication Profile" form completed by the RN and dated 5/3/21 to 7/1/21. The "Medication Profile" listed the following: Lisinopril 20 mg /Hydrochlorothiazide 12.5 mg 1 tablet once per day by mouth. The medication Sulindac was not listed on the medication profile. The Medication Profile was not complete and accurate. 2. Pt. #2. SOC 3/8/21. Primary Diagnosis: Hypertensive Chronic Kidney Disease Stage 5 or End Stage Renal Disease. A home visit was conducted on 6/15/21 at 1:30 PM with the Physical Therapist. During the home visit, an interview was conducted with the Pt.'s caregiver and the patient's medications were reviewed. The Pt.'s caregiver stated that Pt. #2 takes the following according to their list: Carvedilol 6.25 mg oral tablet 1 tablet twice a day, Simvastatin 20 mg oral tablet 1 tablet once a day and Clonazepam 1 mg oral tablet twice daily. The clinical record was reviewed on 6/15/21 at 3:24 PM. The record contained a "Medication Profile" form completed by the RN and dated 5/7/21 to 7/5/21. The record "Medication Profile" listed the following: Carvedilol 6.25 mg oral tablet 1 tablet daily by mouth, Simvastatin 10 mg oral tablet 1 tablet daily by mouth, Clonazepam 1 mg oral tablet three times a day by mouth. The Medication Profile was not accurate. 3. The Agency policy "Policy on Medication Orders" was reviewed on 6/16/21 at 10:50 AM. The policy requires, "The Nurse/Therapist shall record on the Medication Profile all prescribed and over-the-counter medications the client is currently taking ...If the physician changes the medication orfers, the Nurse must add newly ordered drugs or medication changes to the Medication Profile ..." 4. During an interview with the Director of Nursing on 6/16/21 at 12:30 PM, the above findings were confirmed.