Every finding on record at Franklove Home Health Services LLC

EMERGENCY PREPAREDNESS SURVEY The following deficiency is based on the emergency preparedness survey completed on 07/19/21.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. This STANDARD is not met as evidenced by: Based on document review and staff interview, the agency failed to ensure the emergency plan was updated at least every two years. This had the potential to affect all patients receiving services from the agency. The census was 15 patients. Findings include: Review of the Emergency Preparedness binder revealed the emergency plan and policies. The documents lacked evidence they were reviewed and updated within the last two years. This findings was verified in an interview with Staff C on 07/14/21 at 11:35 AM.

Partial Extended Recertification Survey COVID 19 Focused Infection Control Survey An entrance conference was conducted on 07/13/21 at 10:20 AM with administrative personnel, and an exit conference was completed on 07/19/21 at 5:30 PM with administrative personnel. The following deficiencies are based on the COVID 19 Focused Infection Control Survey and the Partial Extended Recertification survey completed on 07/19/21. Franklove Home Health Services LLC 369130, is not in compliance with the requirements found at 42 CFR Part 484 Subpart B, C for Home Health Agencies.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure patients received home health services as written in the plan of care for six of seven medical records reviewed (Patients #1, #2, #3, #4, #5, and #6). This could affect all patients receiving services from the agency. The agency census was 15. Findings include: 1. Review of the medical record for Patient #1 revealed an admission date of 09/16/19. The plans of care dated 05/08/21 to 07/06/21 and 07/07/21 to 09/04/21 revealed orders for 25 hours per week of home health aide services. Review of the medical record from 05/09/21 through 07/10/21 revealed the home health aide services provided as follows: the week of 05/09/21 only 20.75 hours were provided; the week of 05/16/21 only 23.75 hours were provided; the week of 05/23/21 only 19 hours were provided; the week of 05/30/21 only 14 hours were provided; the week of 06/06/21 only 16 hours were provided; the week of 06/13/21 only 15 hours were provided; the week of 06/20/21 only 17 hours were provided; the week of 06/27/21 only seven hours was provided; the week of 07/04/21 only 17.25 hours were provided. The medical record lacked documentation the physician was notified that services were not provided as ordered. 2. Review of the medical record for Patient #2 revealed an admission date of 02/25/21. The plans of care dated 04/26/21 to 06/24/21 and 06/25/21 to 08/23/21 contained orders for skilled nursing visits twice a week, 28 hours per week of home health aide services, and physical therapy twice a week. Review of the medical record from 05/09/21 through 05/22/21 revealed only one skilled nursing visit was provided per week. The week of 06/20/21 three skilled nursing visits were provided. The home health aide notes lacked documentation of visit times, but they were documented in the EVV (Electronic Visit Verification) System logs. The EVV System log included the beginning and end times for all visits. Review of the medical record revealed home health aide services were provided as follows: the week of 05/09/21 25 hours and 29 minutes was provided: the week of 05/16/21 only 25 hours and 31 minutes was provided; the week of 05/23/21 only 25 hours and 59 minutes was provided; the week of 05/30/21 only 25 hours and 21 minutes was provided; the week of 06/06/21 28 hours and 56 minutes was provided; the week of 06/13/21 only 26 hours and 27 minutes was provided; the week of 06/20/21 only 27 hours and 18 minutes was provided; the week of 06/27/21 only 24 hours and 48 minutes was provided; and the week of 07/04/21 28 hours and 10 minutes was provided. The medical record lacked home heath aide visit notes, which would include documentation of tasks/care provided and patient signatures, from 06/02/21 to 07/19/21. Review of the medical record for the week of 06/13/21 and 06/27/21 revealed only one physical therapy visit was provided per week. The medical record did contain a missed visit note for physical therapy on 07/01/21, but the note lacked documentation the physician was notified. The medical record lacked documentation of additional orders or that the physician was notified that all services were not provided as ordered. 3. Review of the medical record for Patient #3 revealed an admission date of 12/29/17. The plans of care dated 04/12/21 to 06/10/21 and 06/11/21 to 08/09/21 contained orders for skilled nursing twice a day and home health aide services 56 hours per week. The medical record lacked documentation of any skilled nursing visits on 05/28/21, 06/05/21, 06/14/21, 06/17/21, 06/21/21, 06/26/21, 07/01/21, 07/02/21, and 07/03/21. The medical record contained documentation of only one skilled nursing visit on 05/27/21, 06/02/21, 06/03/21, 06/04/21, 06/10/21, 06/12/21, 06/19/21, 06/24/21, and 06/25/21. Review of the medical record from 05/09/21 through 07/10/21 revealed home health aide services were provided as follows: the week of 05/09/21 61 hours and 34 minutes was provided; the week of 05/16/21 57 hours and 36 minutes was provided; the week of 05/23/21 62 hours and 34 minutes was provided; the week of 05/30/21 only 53 hours and 53 minutes was provided; the week of 06/06/21 90 hours and 13 minutes was provided; the week of 06/13/21 only 55 hours and 28 minutes was provided; the week of 06/20/21 57 hours and 3 minutes was provided; and the week of 06/27/21 only 55 hours and 29 minutes were provided. The medical record lacked documentation of additional orders or that the physician was notified that services were not provided as ordered. 4. Review of the medical record for Patient #4 revealed an admission date of 03/09/21. The plans of care dated 05/02/21 to 06/30/21 and 07/01/21 to 08/29/21 contained orders for skilled nursing three times per week. The medical record contained only two skilled nursing visits per week for the weeks of 05/09/21 and 06/06/21, and lacked any skilled nursing visits the week of 07/04/21. The medical record lacked documentation the physician was notified that services were not provided as ordered. 5. Review of the medical record for Patient #5 revealed an admission date of 08/21/17. The plans of care dated 04/02/21 to 05/31/21 and 06/01/21 to 07/30/21 contained orders for skilled nursing twice a week and 49 hours per week of home health aide services. The medical record contained three skilled nursing visits the week of 05/30/21. Review of the medical record revealed home health aide services were provided as follows: the week of 05/16/21 50 hours and 42 minutes was provided; the week of 05/23/21 49 hours and 57 minutes was provided; the week of 06/20/21 49 hours and 43 minutes was provided; and the week of 07/04/21 50 hours and one minute was provided. The medical record included the EVV date and time of the home health aide visits but lacked the home health aide visit notes from 05/30/21 to 07/19/21, which would include documentation of tasks/care provided and patient signatures. The medical record lacked documentation of additional orders or that the physician was notified that services were not provided as ordered. 6. Review of the medical record for Patient #6 revealed an admission date of 05/26/20. The plans of care dated 07/25/20 to 09/22/20 and 09/23/20 to 11/21/20 contained orders for weekly skilled nursing visits and 28 hours of home health aide services per week. Review of the medical record from 08/18/20 through 09/19/20 revealed home health aide services were provided as follows: the week of 08/16/20 only 20 hours and 11 minutes was provided; the week of 08/23/20 only 25 hours and 11 minutes was provided; the week of 08/30/20 only 23 hours and nine minutes was provided; the week of 09/06/20 only 24 hours and four minutes was provided; and the week of 09/13/21 only 20 hours were provided. The medical record lacked documentation the physician was notified that services were not provided as ordered. The findings were verified in an interview on 07/19/21 at 4:30 PM with Staff C.

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 medical record review and staff interview, the agency failed to ensure the plans of care included durable medical equipment, supplies, diet, the patient's risk for emergency department visits and hospital re-admission, and advance directive information for seven of seven medical records reviewed (Patients #1, #2, #3, #4, #5, #6, and #7). This could affect all patients receiving services from the agency. The agency census was 15. Findings include: 1. Review of the medical record for Patient #1 revealed an admission date of 09/16/19. The plans of care dated 05/08/21 to 07/06/21 and 07/07/21 to 09/04/21 lacked documentation of the patient's risk for emergency department visits and hospital re-admission and advance directive information. 2. Review of the medical record for Patient #2 revealed an admission date of 02/25/21. The plans of care dated 04/26/21 to 06/24/21 and 06/25/21 to 08/23/21 lacked documentation of the patient's risk for emergency department visits and hospital re-admission and advance directive information. 3. Review of the medical record for Patient #3 revealed an admission date of 12/29/17. The plans of care dated 04/12/21 to 06/10/21 and 06/11/21 to 08/09/21 lacked documentation of the patient's risk for emergency department visits and hospital re-admission and advance directive information. 4. Review of the medical record for Patient #4 revealed an admission date of 03/09/21. The plans of care dated 05/02/21 to 06/30/21 and 07/01/21 to 08/29/21 lacked documentation of the patient's risk for emergency department visits and hospital re-admission and advance directive information. 5. Review of the medical record for Patient #5 revealed an admission date of 08/21/17. The plans of care dated 04/02/21 to 05/31/21 and 06/01/21 to 07/30/21 lacked documentation of the patient's risk for emergency department visits and hospital re-admission and advance directive information. 6. Review of the medical record for Patient #6 revealed an admission date of 05/26/20. The plans of care dated 07/25/20 to 09/22/20 and 09/23/20 to 11/21/20 lacked documentation of the patient's risk for emergency department visits and hospital re-admission and advance directive information. 7. Review of the medical record for Patient #7 revealed an admission date of 05/05/21. The plan of care dated 05/05/21 to 07/03/21 lacked documentation of durable medical equipment, supplies, diet, the patient's risk for emergency department visits and hospital re-admission, and advance directive information. The findings were verified in an interview on 07/19/21 at 4:30 PM with Staff C.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, review of guidance from the Centers for Disease Control and Prevention and staff interview, the agency failed to ensure accepted standards of practice were used to prevent the transmission of COVID 19 during two of three home visits (Patient #3 and Patient #5). This had the potential to affect all patients receiving services from the agency. The census was 15 patients. Findings include: Review of the Centers for Disease Control and Prevention Infection Control Guidance dated 04/27/21 revealed recommendations for use of personal protective equipment by healthcare personnel remain unchanged. Healthcare personnel should wear a N95 respirator or a well fitting facemask during patient encounters. Healthcare settings refers to places where healthcare is delivered and includes, but is not limited to home healthcare. On 07/14/21 at 8:59 AM during the home visit with Patient #3, Staff E was observed without a face mask. At the time of the observation, the patient and staff verified that the aide did not wear a mask during the home visits. On 07/14/21 at 11:38 AM, Staff B stated if the staff were fully vaccinated they were not required to wear face masks during home visits. If a patient had COVID 19, then all required personal protective equipment was to be worn including a face mask. On 07/15/21 at 11:25 AM during the home visit with Patient #5, Staff F was observed without a face mask. At the time of the observation, the patient and staff verified that the aide did not wear a mask during the home visits.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on medical record review and staff interview, the agency failed to ensure patients not receiving skilled care received an on-site supervisory visit at least every 60 days while the aide was providing care for one of two non-skilled medical records reviewed (Patient #1). A total of seven medical records were reviewed. The agency census was 15. Findings include: Review of the medical record for Patient #1 revealed an admission date of 09/16/19. The plans of care dated 05/08/21 to 07/06/21 and 07/07/21 to 09/04/21 contained orders for 25 hours per week of home health aide services. The medical record revealed 12 "Supervisory Visit Records" which lacked documentation of date, time and/or presence of the home health aide. The most recent "Supervisory Visit Record" with a date was 03/10/20. The finding was verified in an interview on 07/19/21 at 4:30 PM with Staff C.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on document review and staff interview, the agency failed to ensure the availability of a clinical manager during all operating hours. This had the potential to affect all patients receiving services from the agency. The census was 15 patients. Findings include: Review of the staff roster revealed one Registered Nurse employed by the agency. Review of the organizational chart revealed a Director of Nursing and the back-up position was currently vacant. On 07/14/21 at 11:38 AM, the Director of Nursing verified he/she was the only Registered Nurse employed at the agency at this time. The Director of Nursing stated they contracted with an agency to provide Registered Nurses for skilled nursing visits as needed. Review of the contract for the contracted agency revealed the contracted agency would provide nurses as needed for home care visits. The contract lacked any mention of administrative duties or back up coverage for the Director of Nursing.