Every finding on record at Gentle Care Inc

During the recertification survey conducted on 02/19/2024 to 02/21/2024 at Gentle Care Inc., a Home Health Agency, Emergency Preparedness was reviewed. Gentle Care Inc. is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies.

A recertification survey was conducted on 02/19/2024 to 02/21/2024 at Gentle Care Inc. The home health agency was in non-compliance with 42 Code of Federal Regulations (CFR) 484 Subpart A-C, Requirements for Home Health Agencies.

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 record review and interview, the provider is unable to demonstrate a completed discharge summary for 2 out of 5 Sampled Patients (SP). SP#4 and SP#5 Findings include: The surveyor performed a closed record review of the SP#4 and SP#5 conducted on 02/19/2024 to 02/21/2024. The SP#4 contained a discharge summary from the agency with a discharge date 02/10/2023; and SP#5 contained a discharge summary from the agency with a discharge date 09/25/2023. The discharge summaries for SP#4 and SP#5 omitted information such as listing the reason for admission to home health; omits the type of services provided and frequency of services; omits any Lab data (as applicable); Omits Medications patient on at discharge and omits a complete summary of care/outcomes in meeting the goals in the Plan of Care. The surveyor conducted an interview with Director of Nursing/Administrator via telephone and in person with alternate administrator on 02/21/2024 at 12:00pm and they acknowledged that the summaries for SP#4 and SP#5 were incomplete, missing the required notations previously mentioned.

A complaint survey for complaint number 2021010670, was conducted on August 24, 2021 at Gentle Care, Inc. The provider was not in compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

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 record review and interviews, the Home Health Agency failed to ensure Staff A followed accepted standards of practice, and their internal policy for staff returning from international travel, before returning to work. Findings include: Interview with Staff A on 8/24/2021 at 1:20 PM revealed: “I went to my country from July 4 to July 11, 2021. I had no signs and symptoms all through out, and I was not exposed to anyone with known COVID-19.” I went back to work on July 12, 2021. I had no signs and symptoms. I wore all personal protective equipment (PPEs).” Review of Staff A’s schedule showed on Monday 7/12/2021 – Completed HHA (Home Health Visit) for SP #1, SP #2, SP #3; Tuesday 7/13/2021 – Completed HHA (Home Health Visit) for SP #1, SP #2, SP #3. Wednesday 7/14/2021 – Completed HHA (Home Health Visit) for SP #1; Missed visit for SP #3 - approved. Review of staff A’s schedule showed staff A did not conduct any home visits from Thursday 7/15/2021 up to Tuesday 7/27/2021. The HR Coordinator stated on 8/24/2021 at 11:50 AM that Staff A went to (their home country) from 7/4/2021 to 7/11/2021. On 7/9/2021 – staff A provided the Home Health Agency a copy of their negative COVID -19 status, a test done in (staff A's home country). Record review of the Home Health Agency's policy & procedure dated August 24, 2021, for returning to work post travel showed that for unvaccinated employee: stay at home for a full 7 days after travel…; If no viral test is done, stay home and self-quarantine for 10 days after travel before returning to work. Review of Centers for Disease control (CDC) Guidance dated July 2, 2021, page 4, showed this Home Health Agency aligned their policy with the CDC guidance on return to work after international travel for unvaccinated individuals. The Home Health Agency failed to ensure staff A followed their internal policy and procedure for staff returning to work from having traveled internationally.