Every finding on record at Four Rivers Home Health of Louisiana

Emergency Preparedness Survey

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to develop and maintain an Emergency Preparedness Plan that was reviewed and updated at least every 2 years. Findings: Review of the agency’s Emergency Preparedness Plan revealed the last documented review was in March 2019. Further review of the Emergency Preparedness Plan revealed the policy had not been completed and revisions had been made in pencil. Interview with S1 ADM/DON on 02/07/2022 at 1:30 p.m. revealed she had not looked at the emeregency prepardness since taking on the role as Administrator/Director of Nursing on 12/04/2022. S1 ADM/DON stated she was not aware the Emergency Preparedness Plan was to be reviewed and updated at least every 2 years.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and 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 PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization 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 PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE 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 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 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 PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE'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 HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a 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 every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA 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 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 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 HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA'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. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to ensure exercises to test the Emergency Plan were conducted at least annually by having a full-scale exercise that is community-based; or an annual individual, facility-based functional exercise and an additional exercise that may include, a second full-scale exercise that is community or facility-based or a tabletop exercise that includes group discussion, as evidenced by failure to have documented evidence that two such exercises had been conducted annually. Interview with S1 ADM/DON on 02/07/2022 at 1:30 p.m. revealed she had not looked at the Emergency Preparedness Policies and Procedures since taking on the role as Administrator/Director of Nursing on 12/04/2022. S1 ADM/DON stated she had not conducted any annual full-scale, individual, facility-based, or tabletop exercises and had no documentation of a any exercises conducted prior to taking on her role as ADM/DON.

Recertification Survey

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on observation and interview the agency failed to ensure patients were advised of the state toll free home health telephone hotline number, contact information, hours of operation, and that its purpose is to receive complaints or questions about local home health agencies for 1 (Patient #2) of 3 (Patient #1, Patient #2 and Patient #3) patients that received a home visit. Findings: Review of Patient #2’s clinical record revealed she had a SOC (Start of Care) date of 12/01/2020. Patient #2’s principle diagnosis was noted as Spastic Quadriplegic Cerebral Palsy and her secondary diagnosis of Athetoid Cerebral Palsy. Observation on 02/07/2023 at 9:30 a.m. during a home visit accompanied by S4 LPN revealed there was no agency folder or documentation in Patient #2’s home with the phone number for the state’s toll-free home health agency hotline. Interview with S4 LPN at the time of observation confirmed there was no agency folder or documentation with the state’s home health agency hotline number in Patient #2’s home and there should have been.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure the patient’s medication profile accurately listed the correct medications the patient was taking for 1 (Patient #2) of 2 (Patient #1 and Patient #2) medications reviewed during home visits. Findings: Review of Patient #2’s CPOC with an admission date of 12/14/2022 and a certification date of 12/14/2022 – 02/11/2023 revealed Patient #1 had a primary diagnosis of Spastic Quadriplegic Cerebral Palsy and secondary diagnosis of Athetoid Cerebral Palsy. Review of Patient #2’s home medications during a home visit conducted on 02/07/2023 at 9:30 a.m. accompanied by S4 LPN revealed Patient #2 was taking all medications listed on her current medication profile except the following medications: 1. Macrodantin Oral 100 mg one by mouth daily. 2. Diphenoxylate-Atropine 0.25 – 0.025 mg one tab every 6 hours as needed. 3. Lactulose 10 gm/15ml take 15 ml by mouth daily. 4. Zofran 4 mg one tab every 6 hours as needed. 5. Hyposcyamine Sulfate 0.125 mg one tab every 4 hours as needed. Interview with S4 LPN during the home visit revealed this was the first time she had ever seen Patient #2. Interview with S1 ADM/DON on 02/07/2023 at 11:30 a.m. confirmed Patient #2 had Skilled Nurse visits performed prior to 02/07/2023. S1 ADM/DON revealed it was the agency’s policy to review all medications each Skilled Nurse visit and update the Medication Profile. S1 ADM/DON confirmed the above listed medications should have been removed from Patient #2’s Medication Profile and had not been

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 record review and interview the agency failed to ensure the patient's Individualized Plan of Care included all medications and treatments for 1 (Patient #4) of 7 sampled patients. Findings: Review of the record revealed Patient #4 admitted to the agency on 01/27/2023 with diagnoses Heart disease, Chronic Kidney Disease, and Long term (current) use of anticoagulants. Review of the Plan of Care for service period 01/27/2023-03/26/2023 and Medication Profile revealed there were no anticoagulant medications listed. Review of Orders and Treatments revealed in part….Obtain PT/INR’s (Prothrombin Time/International Normalized Ratio) as ordered. Review of the Skilled Nurse Interventions revealed in part……Instruct patient/caregiver on possible adverse reactions of Coumadin including nosebleeds, bleeding gums, presence of blood in urine or stool, excessive bruising. Instruct patient/caregiver on measures to promote therapeutic INR levels including taking med at same time each day, avoidance of OTC (over the counter) meds without prior MD (Medical Doctor) approval, diet with consistent Vitamin K intake. SN (Skilled Nurse) to instruct patient/caregiver on action of Coumadin as prevents blood clot formation. SN to obtain PT/INR per venipuncture/Coagucheck q (every) MD order. Instruct patient/caregiver on safety factors to prevent injury with anticoagulant therapy including use of electric razor and soft bristled toothbrush. Review of Physician’s Orders for Patient #4 revealed in part….. 01/27/2023-PT 53.2 INR 4.4. Hold Coumadin today. Recheck PT/INR on 01/28/2023. Verbal order received by S2 RN (Registered Nurse). 01/28/2023- PT 33.2 INR 2.8. Restart Coumadin as follows: 5mg (milligram) po (by mouth) on Monday, Tuesday, Thursday and Saturdays/2.5mg po on Sunday, Wednesday and Fridays. Recheck PT/INR on 01/29/2023. Verbal order received by S2 RN. 01/29/2023 -PT 36.8 INR 3.1. Change Coumadin dosage to 2.5mg daily. Recheck PT/INR on 01/30/2023. Verbal order received by S2 RN. 01/30/2023- PT 38.4 INR 3.2. Continue Coumadin 2.5mg daily. Recheck PT/INR week of 02/05/2023. Verbal order received by S2 RN. 02/06/2023- PT 42.6 INR 3.5. Continue current Coumadin dosage. SN to recheck PT/INR week of 02/12/2023. Verbal order received by S2 RN. Telephone interview on 02/07/2023 at 11:00 a.m. S2 RN revealed she had received a verbal order to restart the patients Coumadin on 01/28/2023 and an order to decrease the dose on 01/29/2023. S2 RN stated she added the skills to the patients POC (Plan of Care) for anticoagulant monitoring but had not updated the patient’s medication profile to reflect the orders for Coumadin. S2 RN stated she should have added the medication and must have forgot. Interview on 02/07/2023 at 11:05 a.m. with S1 ADM/DON confirmed that orders to restart Coumadin on 01/28/2023 and to decrease Coumadin dose on 01/29/2023 had not been added to the patient’s medication profile and POC (Plan of Care) and should have been.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on interview and record review the HHA’s (Home Health Agency's) Governing Body failed to ensure an ongoing program for quality improvement and patient safety was implemented and maintained. Findings: Review of the agency’s QAPI (Quality Assurance and Performance Improvement binder revealed the last documented review was done in 2020. Interview with S1 ADM/DON on 02/07/2023 at 11:25 a.m. revealed she had just taken the position as the Administrator/Director of Nursing on 12/04/2022. S1 ADM/DON stated she had contacted the previous DON on 02/06/2023 to ask her where the QAPI information was. S1 ADM/DON stated she was told there was no QAPI projects being implemented. Further interview with S1 ADM/DON confirmed the HHA had no ongoing Quality Assurance and Performance Improvement projects at this time.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on interview and record review the agency failed to ensure the RN re-assessed a patient’s Stage 2 Pressure Ulcer weekly for 1 (Patient #5) of 7 sampled patients: Findings: Review of Patient #5’s Plan of Care dated 01/07/2023 – 03/07/2023 revealed the primary diagnosis was Pressure Ulcer of Sacral Region and secondary diagnosis of Hypertension. Review of the OASIS admission dated 01/07/2023 revealed Patient #5 had a Stage 2 Pressure Ulcer to her sacral region that was 3.0 cm X 1.5 cm X 0 cm. Review of Patient #5’s Nurses’ notes dated 01/18/2023, 01/25/2023 and 02/01/2023 revealed the patient had not been seen by an RN to re-assess the wound. Interview with S1 ADM/DON on 01/31/2023 at 3:30 p.m. revealed according to the agency policy, an RN should conduct a weekly wound assessment for all wounds and document findings. S1 ADM/DON confirmed Patient #5 had not had a RN skilled nurse visit since 12/22/2022 to re-assess the Stage 2 Pressure Ulcer but should have.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure skilled nursing services ordered by the physician were provided as indicated in the plan of care for 1 (#5) of 7 (#1, #2, #3, #4, #5, #6, and #7) patient records reviewed for services provided per the plan of care and physician orders. The agency’s current census was 87 patients. Findings: Review of Patient #5’s Home Health Care Certification and Plan of Care for Certification Period 01/07/2023 through 03/07/2023 revealed an order for wound care treatment to cleanse wound, dried with gauze, zinc applied to wound bed and cover with padded dressing. Review of Patient #5’s Nurses’ Note dated 01/11/2023 revealed S11 RN provided wound care as follows: Cleansed wound with wound cleanser, applied betadine to the wound and cover with a border non-adhesive gauze. Interview with S1 DON on 02/06/2023 at 4:30 p.m. confirmed that on 01/11/2023 S11 RN performed wound care that was not ordered in the POC. S1 DON stated she should have performed wound care as order by the physician.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure a Registered Nurse (RN), who was familiar with the patient and the patient's Plan of Care, made an onsite visit to the patient's home no less than every 14 days for aide supervisory visits for 1 (Patient #3) of 1 sampled patients with Home Health Aide services. Findings: Review of the visit calendar for Patient #3 revealed the patient was seen by the HHA (Home Health Aide) twice a week starting on 12/20/2022. Further review revealed a HHA supervisory visit by an agency RN had not been conducted for dates 01/01/2023 through 01/21/2023. Interview on 02/07/2023 at 11:30 a.m. with S1 ADM/DON confirmed that no HHA supervisory visit had been conducted by a Registered Nurse from 01/01/2023 through 01/21/2023, and should have been.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to have a governing body (or designated persons so functioning) to assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. Findings: Review of the agency’s survey binder revealed no documentation of who the governing body consisted of. Further review revealed there was no documentation that the governing body had met annually and reviewed the agency’s budget and operational plans or the QAPI program. Interview with S1 ADM/DON on 02/07/2023 at 11:25 a.m. confirmed the above survey binder findings. S1ADM/DON stated she had no documentation of governing body members, meetings or of any reviews performed by the governing body.

Recertification Survey A COVID-19 Focused Infection Control Survey was conducted on 02/25/2021. Patient Census - 103 Abbreviations: QAPI - Quality Assessment/Performance Improvement POC - Plan of Care DM - Diabetes Mellitus SOC - Start of Care mg - milligram mcg - microgram ml - milliliter SQ - subcutaneous OTC - over the counter RN - Registered Nurse LPN - Licensed Practical Nurse COVID - Coronavirus PT/INR - Prothrombin Ratio/International Normalization Ratio IU - International Unit ASHD - Arteriosclerotic Heart Disease

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, record reveiw and interview the agency failed to ensure the clinicians were completing medication reconciliations and updating the records for 2 (#2 and #3) of the 10 total sampled patients out a total census of 103. Findings: 1. Review of patient #2's POC with recertification dates of 01/22/2021 to 03/22/2021 revealed diagnoses that included: Type 2 DM without complications, Chronic Atrial Fibrillation, ASHD of native coronary artery with unspecified angina pectoris, Major Depressive Disorder, Restless leg syndrome, Anxiety Disorder, and history of falling. The POC also revealed a SOC date of 10/23/2020. Further review of the POC revealed no documentation that the patient was to have her medi-planner prefilled weekly. Observation and interview with the patient during the home visit conducted on 02/23/2021 at 9:00 a.m. revealed S4 RN prefilled the patient's medi-planner without the use of the POC or an updated Medication Profile. The patient's medi-planner was prefilled by looking on the bottle and asking the patient if it was correct. Medication discrepancies were as follows, according to the current medication profile: 1. The Medication Profile revealed the patient was taking Escitalopram Oxalate 10 mg one at HS, Glimepiride 4 mg one daily, however the patient revealed the medications had been discontinued over a month ago. 2. The Medication Profile revealed the patient was taking Cyanocobalamin 1000 mcg 2 tabs under tongue once a day, however the patient revealed she only took one tab daily. 3. The Medication Profile revealed the patient was taking Tresiba FlexTouch Subcutaneous 100 Unit/ml inject 56 units SQ at bedtime, however the patient stated she was taking Tresiba 32 Units SQ at bedtime. Interview with S4 RN revealed the patient adjusted the Tresiba dosage herself. 4. The Mediation Profile revealed the following medications were not listed, but the patient verbalized she was taking: D3 25 mcg (1000 IU) once a day and Probiotic OTC once a day orally. Interview of S4 RN on 02/23/2021 at 2:08 p.m. confirmed the Medication Profile had not been updated to include the above mediations. She confirmed she should have used a current Medication Profile to fill the medi-planner and reviewed the profile to ensure the mediations were put in the medi-planner as directed by the physician. 2. Review of patient #3's POC with recertification dates of 01/22/2021 to 03/22/2021 revealed diagnoses that included: Primary Osteopathic, right shoulder, Essential HTN, ASHD of native coronary artery with unspecified angina pectoris, Chronic Pain Syndrome, Vitamin deficiency - unspecified, and history of falling. The POC also revealed a SOC date of 01/28/2020. Observation during the home visit conducted on 02/23/2021 at 10:00 a.m. revealed S3 LPN prefilled the patient's medi-planner without the use of a current Medication Profile or POC. The patient's medi-planner was prefilled by looking on the bottle and asking the patient if it was correct. Medication discrepancies were as follows, according to the current medication profile: 1. OTC medications Aloe Vera Gel one cap once a day - not on Medication Profile, 2. Hair, Skin, Nails one by mouth once a day - not on Medication Profile, 3. Docusate Sodium 100 mg one tab every day was on Medication Profile but the patient stated she was taking 2 tabs, and 4. Fe Sulfate 325 mg one tab daily was on the Medication Profile however the patient revealed it had been discontinued 3 months ago. Interview of S2 DON on 02/23/2021 at 2:08 p.m. revealed the POC and/or Medication Profile should be used when performing a medication review at each skilled nurse visit. She also confirmed the Medication Profile should have been updated to reflect the patient's current medications, including OTC medications.

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 observation, record review and interview, the agency failed to ensure the POC was reviewed and revised to include the skilled nurse frequency (#3), filling of medi-planner (#2 and #3) and the removal of therapy services (#3) for 2 (#2 and #3) of 10 total sampled patients out of total census of 103 patients. Findings: 1. Review of patient #2's POC with recertification dates of 01/22/2021 to 03/22/2021 revealed diagnoses that included: Type 2 DM without complications, Chronic Atrial Fibrillation, ASHD of native coronary artery with unspecified angina pectoris, Major Depressive Disorder, Restless leg syndrome, Anxiety Disorder, and history of falling. The POC also revealed a SOC date of 10/23/2020. Further review of the POC revealed no documentation that the patient was to have her medi-planner prefilled weekly. Observation during the home visit conducted on 02/23/2021 at 9:00 a.m. revealed S4 RN prefilled the patient's medi-planner. Interview with S4 RN on 02/23/2021 at 2:08 p.m. confirmed the POC had not been updated to include filling the medi-planner for each skilled nurse visit and should have. 2. Review of patient #3's POC with recertification dates of 01/22/2021 to 03/22/2021 revealed diagnoses that included: Primary Osteoarthritis, right shoulder, Essential HTN, ASHD of native coronary artery with unspecified angina pectoris, Chronic Pain Syndrome, Vitamin deficiency - unspecified, and history of falling. The POC also revealed a SOC date of 01/28/2020. Review of the patient's HHA clinical record revealed documentation that the resident was receiving skilled nurse visits weekly, and her medi-planner was being filled weekly by the skilled nurse. Further review of the clinical record revealed the patient was not receiving therapy services. Observation during the home visit conducted on 02/23/2021 at 10:00 a.m. revealed S3 LPN prefilled the patient's medi-planner. Interview with patient #3 during the home visit on 02/23/2021 at 10:15 a.m. revealed she had not recieved therapy services in several months. Interview of S2 DON on 02/23/2021 at 2:08 p.m. confirmed the POC had not been updated to include the skilled nurse frequency or the filling of the medi-planner. She also confirmed that the POC was not revised to remove therapy services that the patient was not receiving when the patient's certification was completed, but should have.

Program data CFR(s): 484.65(b)(1),(2),(3) Standard: Program data. (1) The program must utilize quality indicator data, including measures derived from OASIS, where applicable, and other relevant data, in the design of its program. (2) The HHA must use the data collected to- (i) Monitor the effectiveness and safety of services and quality of care; and (ii) Identify opportunities for improvement. (3) The frequency and detail of the data collection must be approved by the HHA's governing body. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to have documentation of an ongoing program for QAPI and patient safety in the agency. Findings: On 2/25/2021 at 2:15 p.m., the facility's QAPI documents were reviewed and the dates reviewed were for 11/2018 to 11/2019. On 2/25/2021 at 2:44 p.m., an interview was conducted with S1 Co-owner and S2 DON, and the agency's QAPI was reviewed. S2 DON stated the agency did not have any current information concerning the agency's QAPI. S2 DON stated that the findings listed in QAPI reports were from 2019. When S2 DON was questioned as to what current issues the agency was tracking in the facility, S2 DON could not provide any documentation of current QAPI or documentation of the areas the facility was addressing as problem areas in the agency. S1 Co-owner and S2 DON confirmed they had not conducted or documented any QAPI processes.

Executive responsibilities for QAPI CFR(s): 484.65(e)(1)(2)(3)(4) Standard: Executive responsibilities. The HHA's governing body is responsible for ensuring the following: (1) That an ongoing program for quality improvement and patient safety is defined, implemented, and maintained; (2) That the HHA-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety, and that all improvement actions are evaluated for effectiveness; (3) That clear expectations for patient safety are established, implemented, and maintained; and (4) That any findings of fraud or waste are appropriately addressed. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to maintain and utilize quality indicator data to monitor the effectiveness and safety of services and quality of care, and failed to identify opportunities for improvement with the frequency and detail of the data collection approved by the agency's governing body. Findings: Review of the agency's QAPI documentation revealed, in part, that the aforementioned required documentation was completed through November, 2019. In interview on 02/25/2021 at 2:45 p.m., S2 DON was questioned as to why there was no QAPI documentation on file after November 2019. S2 DON stated she was not sure what to do with the documentation and was in the process of learning. S2 DON revealed she was responsible for maintaining the documentation. The agency was unable to provide evidence of having any QAPI documentation since November 2019. In interview on 02/21/2020 at 2:43pm, S1 Co-owner and S2 DON indicated they were unable to present the required documentation for the QAPI. S1 Co-owner further indicated there was no documentation of the Governing Body's involvement in the QAPI process.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure that a patient's (#3) electronic medical record contained the correct documentation as reported to S5 Case Manager/RN for 1 (#3) of 10 total sampled patients out of a total of 103 patients. Findings: Review of patient #3's POC with recertification dates of 11/22/2020 to 01/20/2021 and 01/21/2021 to 03/21/2021 revealed diagnoses that included: COVID 19 Acute Respiratory Disease, Essential HTN, Diabetes Mellitus and Non-Hodgkin's Lymphoma. The POC also revealed a SOC date of 11/22/2020. Review of the Skilled Nurse's note dated 12/3/2020 revealed S6 RN documented the patient's PT/INR results were 58.3/4.2, however the communication note documented by S5 RN/Case Manager revealed the patient's PT/INR results were 87.3/7.3. Review of the Skilled Nurses' note dated 12/7/2020 revealed S6 RN documented the patient's PT/INR results were 35.9/3.0, however the communication note documented by S5 RN/Case Manager revealed the patient's PT/INR results were 23.6/2.0. Review of the Skilled Nurses' note dated 12/28/2020 revealed S6 RN documented the patient's PT/INR results were 31.2/2.6, however the communication note documented by S5 RN/Case Manager revealed the patient's PT/INR results were 31.9/2.3. Interview with S5 RN/Case Manager on 02/24/2021 at 9:30 a.m. revealed she had documentation of the PT/INR results that were called into to her to report to the physician. S5 RN/Case Manager provided her PT/INR Monitoring Binder that had documentation that the Communication Notes were documented correctly. Interview with S2 DON on 02/24/2021 at 10:00 am confirmed she and S5 RN/Case Manager had spoken with S6 RN on 3/23/2021 and confirmed the documentation on the communication notes was correct and that the documentation on the Skilled Nurses' notes on 12/3/2020, 12/7/2020 and 12/28/2020 were documented incorrectly.