Every finding on record at Four Season's Home Healthcare, Inc

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 2/22/24. Standard level deficiencies cited.

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 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 undated Emergency Preparedness Plan titled "Emergency Management Policy" was reviewed on 2/21/24 at 9:15 AM. The plan/policy lacked documentation that it was reviewed and revised in the last 2 years. 2. During an interview with the Administrator on 2/21/24 at 9:40 AM, it was stated that the policy has not been revised for the last 2 years. During the same interview, the above finding was confirmed.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on 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 a 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 undated Emergency Preparedness Plan was reviewed on 2/21/24 at 9:15 AM. The plan lacked a facility and community-based risk assessment, using an all-hazards approach. 2. During an interview with the Administrator on 2/21/24 at 9:45 AM, the Administrator confirmed the above finding.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "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 PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE 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 staff interview and review of the Agency's Emergency Preparedness plan, it was determined the Agency failed to ensure staff received Emergency Preparedness training every 2 years. This has the potential to affect all Pts. receiving services. Findings include: 1. The Agency's undated Emergency Preparedness plan was reviewed on 2/21/24 at 9:15 AM. The Plan lacked documentation the staff were provided with Emergency Preparedness training within the past 2 years. 2. During an interview with the Administrator on 2/21/24 at 9:40 AM, it was stated that as of 2/21/24, there has been no documentation of any Emergency Preparedness in-service/training for staff for the last 2 years. 3. During an interview with the Administrator, Director of Nursing and the Director of Operations on 2/21/24 at 4:30 PM, it was confirmed the Agency failed to provide Emergency Preparedness in-service training to staff every 2 years.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 02/22/24. Standard level deficiencies cited. Abbreviations: x = times w = week # = number AM = morning SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients

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 a review of the Agency's Patient Orientation folder, observation during home visits, clinical record review and staff interview, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to provide the name of the Administrator. Findings include: 1. The "Patient Orientation" folder was reviewed on 2/20/24. The folder lacked documentation identifying the Administrator's name. 2. The following home visits were conducted on 2/21/24 from 9:30 AM to 11:15 AM: Pt. #1. SOC 1/21/24. Pt. #2. SOC 8/30/23. Pt. #3. SOC 1/10/24. During the home visits, the "Patient Orientation" folders were observed and lacked the Administrator's name. 3. The clinical records of the following Pts. were reviewed from 2/20/24 to 2/21/24: Pt. #1. SOC 1/21/24. Pt. #2. SOC 8/30/23. Pt. #3. SOC 1/10/24. Pt. #4. SOC 1/3/23. Pt. #5. SOC 8/11/23. Pt. #6. SOC 11/27/23. Pt. #7. SOC 11/2/23. The records lacked documentation the Agency had provided the Administrator's name. 4. During an interview with the Administrator, Director of Nursing and the Director of Operations on 2/21/24 at 2:47 PM, the Administrator confirmed this was the admission folder used for all Pts. admitted to this Agency, and that the Agency failed to provide the name of the Administrator.

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Patient Orientation folder, observation during home visits, clinical record review and staff interview, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to provide information regarding Federal and state funded organizations that provide service in the patient's community. Findings include: 1. The "Patient Orientation" folder was reviewed on 2/20/24. The folder contained a section titled, "Local Resources (Agency to complete)". This section required Agency staff to write in the name, address and phone number for the "Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Center" for the county/area the Pt. resides. 2. The following home visits were conducted on 2/21/24 from 9:30 AM to 11:15 AM: Pt. #1. SOC 1/21/24. Pt. #2. SOC 8/30/23. Pt. #3. SOC 1/10/24. During the home visits, the "Patient Orientation" folders were observed. The section requiring Agency staff to write in the name, address and phone number for the "Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Center" for the county/area the Pt. resides was left blank. 3. The clinical records of the following Pts. were reviewed from 2/20/24 to 2/21/24: Pt. #1. SOC 1/21/24. Pt. #2. SOC 8/30/23. Pt. #3. SOC 1/10/24. Pt. #4. SOC 1/3/23. Pt. #5. SOC 8/11/23. Pt. #6. SOC 11/27/23. Pt. #7. SOC 11/2/23. The records lacked documentation the Agency had provided the names and contact information of Federal and state funded organizations that the Pt. resides. 4. During an interview with the Administrator, Director of Nursing and the Director of Operations on 2/21/24 at 2:47 PM, the Administrator confirmed the Agency failed to provide Pts. the names and contact information of Federal and state funded organizations.

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 a review of clinical records and staff interview, it was determined in 3 of 7 (Pts. #2, 6 and 7) clinical records reviewed, the Agency failed to ensure the initial assessment visit was done within 48 hours of the referral date. Findings include: 1. Pt. #2 was admitted for skilled home health on 8/20/23 with the primary diagnosis of Hemiplegia Following Cerebral Infarction Affecting Left Nondominant Side. The clinical record was reviewed on 2/21/24. The record contained the Physician's order/referral dated 8/15/23 and faxed from the Physician's office to the Agency on 8/15/23, requiring "Close monitor from visiting nurse". The SOC comprehensive assessment completed by the RN was dated 8/30/23 (15 days after receipt of the referral). As of 2/21/24, the record lacked documentation the Agency initiated service within 48 hours after receiving the referral. 2. Pt. #6 was admitted for skilled home health on 11/27/23 with the primary diagnosis of Chronic Obstructive Pulmonary Disease with Acute Exacerbation. The clinical record was reviewed on 2/21/24. The record contained the Physician's order/referral dated 11/23/23, indicating Pt. #6 will be discharged from an inpatient facility on 11/23/23. The referral was faxed to the Agency on 11/23/23. The SOC comprehensive assessment was completed by the SN and dated 11/27/23 (4 days after inpatient discharge and receipt of the referral). As of 2/21/24, the record lacked documentation the Agency initiated service within 48 hours after receiving the referral. 3. Pt. #7 was admitted for skilled home health on 11/2/23 with the primary diagnosis of Unspecified Polyosteoarthritis. The clinical record was reviewed on 2/21/24. The record contained the Physician's order/referral dated10/27/23, and faxed from the Physician's office to the Agency on 10/27/23. The SOC comprehensive assessment was completed by the SN and dated 11/2/23 (6 days after receipt of the referral). As of 2/21/24, the record lacked documentation the Agency initiated service within 48 hours after receiving of the referral. 4. During an interview with the Administrator, Director of Nursing and the Director of Operations on 2/21/24 at 12:47 PM, the Administrator confirmed the Agency failed ensure the initial assessment visit was done within 48 hours of the referral date.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined in 2 of 7 (Pts. #2 and 5) clinical records reviewed, the Agency failed to ensure staff provide service as ordered by the Physician, and indicated in the Plan of Care. 2. Pt. #5 was admitted for skilled home health on 12/9/23 with a primary diagnosis of Type 2 Diabetes Mellitus with Peripheral Angiopathy without Gangrene and secondary diagnosis which include but not limited to Chronic Diastolic (Congestive) Heart Failure. The clinical record was reviewed on 2/21/24 and included a POC for the certification period of 12/9/23 to 2/6/24 requiring: “Orders for Discipline and Treatment…Pain Management: SN to provide skilled assessment…recording and reporting pain…Chronic Diastolic Congestive Heart Failure: SN to record patient’s weight weekly…Diabetes Mellitus with Chronic Kidney Disease: SN to check finger stick for blood glucose analysis each visit…” The SN Visit notes dated: 1/3/24 – lacked documentation of weight and pain assessment. 1/13/24 – lacked documentation of blood glucose result and weight. 1/16/24 – lacked documentation of weight and pain assessment. 1/24/24 – lacked documentation of weight, blood glucose result and pain assessment. 2/8/24 – lacked documentation of weight. 3. The policy titled, “Orders for care” which was reviewed on 2/22/24 required, “The Agency will obtain orders and provide care in accordance with the physician’s and/or non-physician practitioner’s orders…” 4. During an interview with the Administrator, Director of Nursing and Director of Operations on 2/21/24 from 2:45 to 4:30 PM, it was stated that the Agency should follow physician orders in the POC. During the same interview, the above findings were confirmed. Findings include: 1. Pt. #2 was admitted for skilled home health on 8/20/23 with the primary diagnosis of Hemiplegia Following Cerebral Infarction Affecting Left Nondominant Side. The clinical record was reviewed on 2/21/24. The record contained the POC effective 12/28/23 required: "SN Frequency: 1eow9" (1 time every other week for 9 weeks). The record contained documentation the SN provided service on 1/24/24 (week of 1/21/24 to 1/27/24). The record lacked documentation the SN provided service during the week of 2/4/24 to 2/10/24.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interviews, it was determined that in 4 of 7 (Pts. #1, 3, 5 and 6) clinical records reviewed, the agency failed to assess the need for Pneumococcal Pneumonia and/or Influenza vaccines. Findings include: 1. The following clinical records were reviewed from 2/20/24 to 2/21/24. Pt. #1. SOC 1/21/24. Lacked inquiry for Pneumococcal Pneumonia. Pt. #3. SOC 1/10/24. Lacked inquiry for Pneumococcal Pneumonia. Pt. #5. SOC 8/11/23. Lacked inquiry for Pneumococcal Pneumonia. Pt. #6. SOC 11/27/23. Lacked inquiry for Influenza and Pneumococcal Pneumonia. 2. The policy titled, “Influenza and Pneumonia Vaccination Program” which was reviewed on 2/22/24 required: “Policy: I. Agency staff will annually administer or arrange for the administration of vaccination against Influenza to each qualifying patient/client. II. Agency staff will administer or arrange for Pneumonia vaccines to be administered to each qualifying patient/client and who has not received this immunization prior to or upon service initiation... Agency staff will document in the patient/client’s medical record that an annual vaccination against influenza was administered/arranged, refused or medically contraindicated or that the patient/client is not a member of a vaccination priority population. V. For Pneumonia vaccines, agency staff will document in each patient’s/client’s medical record that a vaccination against pneumococcal pneumonia was offered and administered, arranged, refused, or medically contraindicated or the patient/client is not a member of a vaccination priority population.” 3. During the entrance conference interview on 2/20/24 at 9:30 AM, the Director of Nursing stated the RN is required to assess the patient's Influenza and Pneumococcal Pneumonia vaccination status at the SOC and this information is documented in the initial comprehensive assessment. 4. During an interview with the Administrator, Director of Nursing and Director of Operations on 2/21/24 from 2:45 PM to 4:30 PM, the Director of Nursing confirmed the initial comprehensive assessment/clinical records lacked an inquiry for the Pneumococcal Pneumonia and Influenza vaccines.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Patient Orientation folder, observation during home visits, clinical record review and staff interview, it was determined in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6 and 7) clinical records reviewed, the Agency failed to provide the name of the Clinical Manager. Findings include: 1. The "Patient Orientation" folder was reviewed on 2/20/24. The folder lacked documentation identifying the Clinical Manager's (Director of Nursing) name. 2. The following home visits were conducted on 2/21/24 from 9:30 AM to 11:15 AM: Pt. #1. SOC 1/21/24. Pt. #2. SOC 8/30/23. Pt. #3. SOC 1/10/24. During the home visits, the "Patient Orientation" folders were observed and lacked the Clinical Manager's name. 3. The clinical records of the following Pts. were reviewed from 2/20/24 to 2/21/24: Pt. #1. SOC 1/21/24. Pt. #2. SOC 8/30/23. Pt. #3. SOC 1/10/24. Pt. #4. SOC 1/3/23. Pt. #5. SOC 8/11/23. Pt. #6. SOC 11/27/23. Pt. #7. SOC 11/2/23. The records lacked documentation the Agency had provided the Clinical Manager's name. 4. During an interview with the Administrator, Director of Nursing and the Director of Operations on 2/21/24 at 2:47 PM, the Administrator confirmed this was the admission folder used for all Pts. admitted to this Agency, and that the Agency failed to provide the name of the Clinical Manager.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined in 2 of 2 (Pts. #6 and 7) clinical records reviewed, the Agency failed to ensure the Physician was sent a copy of the discharge summary. Findings include: 1. Pt. #6 was admitted for skilled home health on 11/27/23 with the primary diagnosis of Chronic Obstructive Pulmonary Disease with Acute Exacerbation. The clinical record was reviewed on 2/21/24. The record contained the Agency's discharge summary completed by the SN on 12/16/23. The record lacked documentation the Agency sent a copy of the summary to the Physician. 2. Pt. #7 was admitted for skilled home health on 11/2/23 with the primary diagnosis of Unspecified Polyosteoarthritis. The clinical record was reviewed on 2/21/24. The record contained the Agency's discharge summary completed by the SN on 1/5/24. The record lacked documentation the Agency sent a copy of the summary to the Physician. 3. During an interview with the Administrator, Director of Nursing and the Director of Operations on 2/21/24 at 12:47 PM, the Administrator confirmed the Agency failed to ensure the Physician was sent a copy of the discharge summary.

Recertification survey conducted. Standard level deficiencies cited. A Focused Infection Control survey was completed on 3/18/2021. Standard level deficiency cited. Abbreviations: PsOC= Plans of Care POC= Plan of Care SOC= Start of Care AM= Morning PM= Afternoon/Evening RN= Registered Nurse Pt./Pts.= Patient/Patients mg= Milligrams COVID-19= Coronavirus 2019

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: A. Based on review of clinical records, observations and interviews during home visits, and staff interview it was determined the agency failed to ensure PsoC included all requirements. This was found in 2 of 3 home visits conducted (Pt #2 and 1). Findings include: 1. Pt #2. SOC 2/22/21. Primary Diagnosis: Polyosteoarthritis. Pt. #2's clinical record was reviewed on 3/15/21 at 1:00 PM. The record included a POC effective 2/22/21. A home visit was conducted with a physical therapist on 3/15/21 at 3:00 PM. During the home visit Pt. #2 presented medications for review which included Xarelto 15 mg 1 Tab by mouth daily, dated 11/30/2020, Mirtazapine 15 mg 1 Tab by mouth at bedtime, dated 11/30/20 and Omeprazole 40 mg 1 Tab daily, dated 2/16/21. During a home visit interview Pt. #2 stated that the medications presented were taken daily since prescribed. These medications were not included in the POC dated 2/22/21. 2. Pt. # 1. SOC 1/8/21. Diagnosis: Benign Prostatic Hyperpiesia with lower urinary tract symptoms. A home visit was conducted with the RN/Director of Nursing on 3/15/21 at 2:30 PM. During the home visit, Pt. 1's caregiver stated that Pt. #1 was on pureed diet and takes thickened liquids, and this statement was also confirmed by the RN. During the home visit, the RN also confirmed that Pt. #1 still had a pressure ulcer on the buttock and instructed the caregiver to continue to apply zinc oxide to the area. The clinical record was reviewed on 3/15/21 at 1:00 PM and again on 3/16/21 at 9:30 AM. The record contained a POC for certification period for 2/3/21 to 4/3/21 which lacked documentation of Pt. #1's current nutritional requirements. The same POC also lacked documentation of patient specific interventions for pressure ulcer care and the treatments to be used for the wound. 3. During an interview with the Administrator and the Director of Nursing on 3/16/21 at 2:15 PM and 2:40 PM, the above findings were confirmed. The Administrator and Director of Nursing stated the POC should include the above requirements.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: . A. Based on Agency staff interviews, COVID-19 binder review and review of Agency policies, it was determined the Agency failed to implement their infection control surveillance plan and, failed to track and monitor staff and patients who were potentially exposed to COVID-19, as per infection control policy. This has the potential to affect patients who were receiving services from staff who were potentially exposed to COVID-19 during that service period. Findings include: 1. During the entrance interview with the Administrator and Director of Nursing on 3/15/21 at 10:05 AM, the Administrator stated that there were 4 staff members and several patients admitted since March 2020 who tested positive for COVID-19. 2. The Agency's "COVID-19 Information Binder" was reviewed on 3/15/21 at 10:00 AM. The binder contained the form "Employee Infection Control Log" which included names of staff who were identified to have an infection/tested positive for COVID-19, signs and symptoms, the type of infection, treatment and follow up action. The same form lacked documentation of patients who received direct services from the staff who tested positive for COVID-19 and actions taken to monitor patients. The binder also included the form "Patient/Employee Infection Report" for E1 (Director of Nursing), E2 (Registered Nurse) and E3 (Physical Therapist) which included documentation of treatments, laboratory tests, and comments/summary. The report included the statement "last patient seen on" but lacked documentation of dates of occurrences and names of patients who received direct services from the staff who tested positive and actions taken to monitor these patients. 3. Pt. #4. SOC: 2/3/21. Diagnosis: COVID-19. The clinical record was reviewed on 3/15/21 at 1:00 PM. The record contained skilled nursing visit notes and physical therapy notes indicating that Pt.#4 was receiving skilled services since 2/3/21. As of 3/17/21, the Agency binder lacked documentation of Pt. #4 having COVID-19 infection and lacked documentation of actions taken for tracking/monitoring the infection. During an interview with the Administrator on 3/17/21 at 9:30 AM, the Administrator confirmed all patients/staff who tested positive for COVID-19 should be identified on the binder and that Pt. #4 was not on the infection report. 4. The Policy titled "Infection Control Program" was reviewed on 3/16/21 at 11:00 AM and contains the following: "Purpose: ...The program improves patient/client health outcomes through risk reduction, prevention, identification and control of infections and communicable diseases in patients/clients and staff ....The Infection Control Program will include: C. A system that coordinates: 1. Surveillance for the occurrence of an infection, 2. Identification of the occurrence, 3. Implementing appropriate preventive measures, 4. Implementing appropriate measures to control infection, 5. Review of the date collected to evaluate for trends, patterns, etc., 6. Reporting the data and any identified trends as appropriate ... D. A plan for influx of potentially infectious patients/clients..." 5. During an interview with the Administrator and the Director of Nursing on 3/16/21 at 2:45 PM and on 3/17/21 at 9:30 AM, the above findings were confirmed. The Administrator confirmed that the Agency lacked documentation for surveillance activities for COVID-19.