Every finding on record at Frontier Health Care Services, LLC

SUBSTANTIAL ALLEGATION SURVEY SUBSTANTIAL ALLEGATION 107696 The following deficiencies are based upon substantial allegation 107696 completed on 07/31/24. Frontier Health Care Services is not in compliance with the requirements at 42 CFR Part 484, Subpart B, C, 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 record review and interview, the facility failed to ensure each patient received personal care services as written. This affected one (Patient #17) of three patients reviewed. This could affect all patients receiving services from the facility. The active census was 16. Findings include: Review of the medical record for Patient #17 revealed an admission date of 10/02/23. Diagnoses included type 2 diabetes, myocardial infarction, chronic obstructive pulmonary disease, and hypertension. Functional limitations included bowel and bladder incontinence. He used a cane. The patient was oriented with a fair prognosis. Review of the Passport Service Plan Report referral documented home health aide (HHA) services were to be 14 hours a week. Assistance was to be provided with skin care, hair care, shaving, oral care, ambulation, housekeeping, vacuum, sweep, wet mop, dusting, dishes, refrigerator, laundry, change bed linens, shopping, bathing, dressing/grooming, mobility/transfer, toileting, trash removal, grocery list preparation and shopping and prescription pickup. Review of the HHA timesheets revealed no personal hygiene was provided for the time frame of 02/19/24 to 03/16/24. During an interview on 07/29/24 at 3:15 P.M., Office Manager Staff G verified the HHA did not document on the timesheets the provision any personal care services.

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 facility failed to ensure plans of care included the services to be provided and the frequency and duration of visits to be made. This affected two (Patient's #5 and #17 of three records reviewed. The active census was 16. Findings include: 1. Record review revealed Patient #17 was admitted on 10/02/23. Diagnoses included type 2 diabetes, myocardial infarction, chronic obstructive pulmonary disease, and hypertension. Functional limitations included bowel and bladder incontinence. He used a cane. The patient was oriented with a fair prognosis. Review of the plan of care and certification assessment dated 01/30/24 to 03/29/24 revealed no home health aide (HHA) hours listed or the frequency of care or services to be provided by the HHA. Review of the Passport Service Plan Report referral documented aide services were to be 14 hours a week. Assistance was to be provided with skin care, hair care, shaving, oral care, ambulation, housekeeping, vacuum, sweep, wet mop, dusting, dishes, refrigerator, laundry, change bed linens, shopping, bathing, dressing/grooming, mobility/transfer, toileting, tub and sink care, trash removal, grocery list preparation and shopping and prescription pickup. 2. Record review revealed Patient #5 was admitted on 06/20/23. Diagnoses included diabetes, complex regional pain syndrome, anxiety disorder, and chronic venous insufficiency of bilateral lower extremities. Functional limitations included amputation and endurance. The patient was forgetful and depressed. Review of the current plan of care and certification assessment for the dates 06/14/24 to 08/12/24 revealed there were no HHA hours listed or services to be provided by the HHA. Review of the insurance referral documented HHA services were to be 14 hours a week. Assistance was to be provided with meal preparation, housekeeping, laundry, shopping, bathing, dressing/grooming, mobility/transfer, toileting, feeding and supervision. During an interview on 07/29/24 at 3:15 P.M., Office Manager Staff G verified the aide hours and frequency were to be on the plan of care and the certification assessment, and the hours were not listed as well as the HHA services to be provided for both patients.

Extended Survey Substantial Allegation Survey Substantial Allegation 62205 An entrance conference was conducted with the administrative staff (Administrator and Office Manager) on 03/29/22 at 9:45 AM, and an exit conference was completed with the administrative staff on 04/01/22 at 11:30 AM. The following deficiencies are based on the Substantial Allegation Survey completed on 04/01/22, Frontier Healthcare Services 368363 was not in compliance with regulations at CFR Part 484, Subpart B, C for Home Health Agencies. On 03/29/22 at 4:42 P.M. the Administrator and Office Manager were informed a determination of Immediate Jeopardy was made under Infection Control. On 03/29/22 only 35% of the facility staff were vaccinated against COVID-19 creating a likelihood of serious harm. An action plan was received on 03/30/22 and approved on 03/31/22 at 11:30 PM. On 04/04/22 at 11:30 AM, the Office Manager and the Administrator were informed the Immediate Jeopardy was removed on 04/01/22 when staff were educated on the facility COVID-19 vaccine policy. The agency is precluded from offering its own aide training and/or competency evaluation program for a period of two years from the exit date of this survey

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on review of the Centers for Medicare & Medicaid Services (CMS) memorandum QSO-22-09-ALL Attachment G, record review and staff interview, the facility failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19 and failed to ensure at least 90% of the staff were vaccinated within 30 days from the effective date of the healthcare worker vaccine mandate. The agency’s percentage of vaccinated staff for COVID-19 was 35%. (G 687). The cumulative effect of these systemic practices resulted in the agency's inability to ensure that the patients' infection control needs would be met. See G687

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of the Centers for Medicare & Medicaid Services QSO memo 22-09-ALL Attachment G, review of facility COVID-19 vaccination records, and staff interview, the facility failed to ensure all staff were fully vaccinated against COVID-19 at 100% compliance within the effective date of the healthcare worker vaccine mandate. Additionally, the agency failed to develop any COVID-19 vaccination policies and procedures, the agency failed to develop a process to track and document vaccine status of all staff and staff with boosters per the Centers for Disease Control and Prevention (CDC), failed to develop a process to track and document information provided by staff requesting exemptions and who agency has granted, failed to develop a process to ensure all documentation confirms clinical contraindications, supports staff request for medical exemptions and must be signed and dated by the Physician, failed to develop a process to document and evaluate religious exemptions, and failed to develop a process to track and document staff where vaccine is delayed, as recommended by the CDC. The agency’s percentage of vaccinated staff for COVID-19 was 35%. This affected 13 of 20 staff members (Office Manager Staff B, and 12 Home Health Aides: Staff C, Staff D, Staff E, Staff F, Staff G, Staff H, Staff I, Staff J, Staff L Staff M, Staff N, and Staff O). This affected ten patients (#1, #6, #7, #8, #10, #11, #12, #13, #15 and #17) who were receiving care from 12 unvaccinated home health aide staff. The agency census was 18. Findings include: Review of QSO memo 22-09-ALL Attachment G, dated 01/14/22, revealed within 60 days of issuance of this memorandum the facility must demonstrate policies and procedures are developed and implemented for ensuring all facility staff, regardless of clinical responsibility or resident contact are vaccinated for COVID-19 and 100% of staff have received the necessary doses to complete the vaccine series, or have been granted a qualifying exemption, or are identified as having a temporary delay as recommended by the Centers for Disease Control and Prevention (CDC). Interview on 03/29/22 at 9:45 AM, the Administrator revealed the agency has not developed policies on Covid-19 vaccination requirements because he/she was confused with some of the rules. The Administrator could not say for sure who was vaccinated and who was not out the 20 agency employees. The Administrator verified he/she has not provided employees with any direction on the process of obtaining exemptions. Review on 03/29/22 of the Home Health Agency’s Employee Roster revealed there were 20 current employees. Review on 03/29/22 of the Home Health Agency’s employee vaccination cards revealed seven of the 20 employees were fully vaccinated and two of the 20 employees were partially vaccinated. There were no exemptions on file for any employees. The agency vaccination rate was calculated at 35%. There were no COVID-19 vaccinations or exemptions on file for the following staff who provided direct patient care Staff C, Staff D, Staff E, Staff F, Staff G, Staff H, Staff I, Staff J, Staff L Staff M, Staff N, and Staff O. The Office manager, Staff B, had no evidence of being vaccinated or having an exemption. Interview with Staff B on 03/29/22 at 2:07 PM confirmed she had not been vaccinated or COVID-19 or had an exemption. Staff B also verified Staff C, Staff D, Staff E, Staff F, Staff G, Staff H, Staff I, Staff J, Staff L Staff M, Staff N, and Staff O had not received the COVID-19 vaccination or had an exemption on file. Staff B stated the agency was not tracking employee vaccinations and/or exemption statuses. Staff B identified 10 patients (#1, #6, #7, #8, #10, #11, #12, #13, #15 and #17) were receiving care from the unvaccinated home health aide staff.