Every finding on record at Global Home Care, Inc

On January 4, 2022, through January 5, 2022, an Emergency Preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs. At the survey, Global Home Care was found to be not in substantial compliance with the requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness. The following condition level deficiency was identified: 42 CFR §484.102 Emergency Preparedness.

Establishment of the Emergency Program (EP) CFR(s): 484.102 §403.748, §416.54, §418.113, §441.184, §460.84, §482.15, §483.73, §483.475, §484.102, §485.68, §485.625, §485.727, §485.920, §486.360, §491.12 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility, except for Transplant Programs] must 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: * (Unless otherwise indicated, the general use of the terms "facility" or "facilities" in this Appendix refers to all provider and suppliers addressed in this appendix. This is a generic moniker used in lieu of the specific provider or supplier noted in the regulations. For varying requirements, the specific regulation for that provider/supplier will be noted as well.) *[For hospitals at §482.15:] The hospital must comply with all applicable Federal, State, and local emergency preparedness requirements. The hospital must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: *[For CAHs at §485.625:] The CAH must comply with all applicable Federal, State, and local emergency preparedness requirements. The CAH must develop and maintain a comprehensive emergency preparedness program, utilizing an all-hazards approach. The emergency preparedness program must include, but not be limited to, the following elements: This CONDITION is not met as evidenced by: Based on record review and interview, the agency failed to ensure their emergency preparedness policies and procedures were reviewed and updated, have policies that addressed the use of volunteers and the integration of State or Federal health care professionals, update their communication plan, and develop and maintain an Emergency Preparedness training and testing program. These deficient practices could affect all 56 of the agency's current patients. The cumulative effect of these systemic problems results in the agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation at 42 CFR 484.102, Emergency Preparedness. Findings include: 1. The agency did not review and update their emergency preparedness policies and procedures every 2 years. (See E0013) 2. The agency did not have policies regarding the use of volunteers and the integration of State or Federal health care professionals. (See E0024) 3. The agency 's communication plan had not been updated since 2017. (See E0029) 4. The agency did not develop and maintain an Emergency Preparedness training and testing program. (See E0036)

Development of EP Policies and Procedures CFR(s): 484.102(b) §403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b). (b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually. *Additional Requirements for PACE and ESRD Facilities: *[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years. *[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure their emergency preparedness policies and procedures were reviewed and updated at least every 2 years, resulting in the agency's inability to ensure staff actions during an emergency aligned with current practices and guidelines. These practices could negatively affect the health and safety of the agency's 56 current patients in the event of an agency-based emergency or community disaster. Findings include: The agency's Emergency Preparedness Plan was reviewed with the Administrator (Adm #1) on 1/5/22 at 1:55 p.m. During the review, it was noted that there was no indication as to when the agency's emergency policies and procedures were reviewed or updated. The policies and procedures for Snow Emergency, Severe Weather, and Floods were all dated October 2010. The agency's policy titled, Emergency Management Plan (policy 7-001), was dated October 2015. The findings were acknowledged by Adm #1 at the time of discovery.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure to have a policy that addressed the use of volunteers including the process and role for integration of State or Federal designated health care professionals to address surge needs during an emergency, resulting in the potential to negatively affect the health and safety of the agency's 56 current patients in the event of an agency-based emergency or community disaster. Findings include: The agency's Emergency Preparedness Plan was reviewed with the Administrator (Adm #1) on 1/5/22 at 1:55 p.m. During the review, it was noted that there was no documented evidence that the agency had developed a policy that addressed the use of volunteers including the process and role for integration of State or Federal designated health care professionals to address surge needs during an emergency. The finding was confirmed by Adm#1 during the interview on 1/5/22 at 1:55 p.m.

Development of Communication Plan CFR(s): 484.102(c) §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to update their communication plan at least every 2 years, resulting in the inability to coordinate patient care for the agency's 56 current patients in the event of an agency-based emergency or community disaster. Findings include: The agency's Emergency Preparedness Plan was reviewed with the Administrator (Adm #1) on 1/5/22 at 1:55 p.m. During the review, it was noted that there was no indication as to when the agency's communication plan was last reviewed or updated. The emergency plan contained a document that detailed the agency's active employee list with names, discipline, phone numbers, and date of hire. The active employee list was dated 6/14/2017. At the time of discovery, Adm#1 confirmed that the employee list and the communication plan had not been updated since 2017.

EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to develop and maintain an Emergency Preparedness training and testing program that is based on the emergency plan, risk assessment, policies, procedures, and the communication plan. Resulting in the agency's inability to ensure staff actions align with the emergency plan. These practices could negatively affect the health and safety of the agency's 56 current patients in the event of an agency-based emergency or community disaster. Findings include: The agency's Emergency Preparedness Plan was reviewed with the Administrator (Adm #1) on 1/5/22 at 1:55 p.m. During the review, it was noted that there was no documented evidence that the agency had developed a training and testing program based on the Emergency Preparedness plan to guide personnel and agency actions during an emergent situation. Adm #1 presented for review, documentation of a Winter Storm Drill dated 4/26/19. There was no documentation to indicate who had participated in the winter storm drill. There was no documentation of an agency-based emergency drill since April of 2019. No documentation of a community-based drill, an actual emergency event, and no documentation of the agency's efforts during the Covid-19 pandemic. During the interview on 1/5/22 at 1:55 p.m., Adm#1 was asked to provide documentation of staff training in the agency's Emergency Preparedness plan. No documentation was provided for review by the time of the survey exit on 1/5/22 at 4:15 p.m. During an interview on 1/5/22 at 2:32 p.m., the clinical manager (CM#1) was queried regarding aspects of the agency's emergency plan. CM#1 was unable to correctly identify the patient prioritization system utilized by the agency. CM#1 stated that patients rated at level 1 are the highest priority to be seen during an emergency. The agency's emergency plan indicates level 3 patients as the highest priority. CM#1 was queried regarding which local radio station to tune to in the event of an emergency according to the agency's emergency plan. CM#1 was unable to identify the appropriate radio station identified in the agency's plan. The findings were acknowledged by Adm #1 at the time of discovery.

The following Condition and Standard level deficiencies were identified at A Medicare authorized Complaint Investigation (MI00061231) concurrent with a Focused Infection Control Covid-19 survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 1/4/22 to 1/5/22 at: Global Home Care 1883 East Maple Rd. Troy, MI 48083 This agency had no additional branch locationsServices provided: Skilled Nursing, Physical Therapy, Occupational Therapy, Speech Therapy, Medical Social Work and Home Health Aide.Four (4) records reviewed without home visits. Allegations: 1) It was alleged the agency failed to provide catheter care - Substantiated. 2) It was alleged the agency failed to address change in condition - Substantiated. 3) It was alleged the agency failed to provide care to pressure ulcers. - Unsubstantiated 4) It was alleged the agency failed to appropriately discharge the patient. - Substantiated 5) It was alleged the agency is short staffed. - Substantiated At the conclusion of the survey, the following conditions were identified: 42 CFR § 484.50 Patient Rights. 42 CFR § 484.70 Infection Control. 42 CFR § 484.102 Emergency Preparedness. As a result of the Condition level noncompliance, the Agency is prohibited for 2 years from offering a Home Health Aide training and competency evaluation or a competency evaluation program as specified in 42 CFR §484.80(f)(3).

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on record review and interview, the agency discharged the patient based on the agency's needs, not the patient's needs or acuity and failed to provide appropriate care and services and address a change in condition. These deficient practices affected the health and well-being of this 1 (MR#1) patient. The cumulative effect of these systemic problems results in the agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation at 42 CFR 484.50, Patient Rights. Findings include: 1. The agency discharged the patient to suit their own lack of staffing. (See G454) 2. The agency failed to provide immediate care for an indwelling urinary catheter (Foley) that became dislodged/disconnected and leaked urine onto the patient's wounds. (See G482)

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency discharged the patient based on the agency's needs, not the patient's needs or acuity for 1 of 1 (MR#1) records reviewed in which the patient was inappropriately discharged, resulting in no assistance in transferring this patient to the care of another agency. Findings include: MR#1: This 60-year-old patient was admitted to home care on 10/18/21 with diagnoses that included hypertensive chronic kidney disease, congestive heart failure, pressure ulcers on both buttocks, lack of bladder control due to a nerve condition, and paralysis of the lower legs and lower body. During record review on 1/4/22, it was noted that the patient was discharged from the agency on 10/29/21. The start of care assessment completed by the Clinical Manager (CM#1) on 10/18/21, notes that the patient is morbidly obese and "quadriplegic of lower extremities... and seems frustrated with her care" (this statement by CM#1 indicates the patient is paraplegic). The 10/18/21 plan of care orders skilled nursing services to be provided twice in week one and then one visit per week for eight weeks. The nurse is to care for the patient's pressure ulcers and provide monthly or as needed Foley catheter changes. The second nursing visit was provided by RN#1 (registered nurse) on 10/18/21. Wound care was provided, labs were drawn, and the Foley catheter was changed that day. The clinical record contained a communication note dated 10/18/21 that stated it was "better to have RN#3 than RN#1 in regards to CM#1's report." A 10/19/21 communication note states, "RN#3 declined the assignment after she talked to the patient & seeing the needs & request of the patient." A communication note on 10/21//21 documents that the patient called the office asking for supplies and inquiring about her nurse. On 10/27/21 RN#1 completed a skilled nursing visit with this patient. A communication note on 10/27/21 notes that RN#1 reports that she just did an almost 2 hour visit, the patient is morbidly obese with a wound on the back..."This is a hard case." Two days later (10/29/21) RN#1 documented a comprehensive assessment visit to discharge the patient from home care services. There was no documented assessment of the patient's Foley catheter, no wound care, and no wound assessment. The visit note states, "Patient will be discharged from home health services today. Patient very difficult to rendered (sic) care. Patient will look for another home care." RN#1 was not available for an in-person or telephone interview during the complaint investigation. During an interview on 1/5/22 at 10:34 a.m., RN#2 (registered nurse) explained that there were only 2 nurses, RN#3 and RN#1, available in the area to care for this patient. RN#3 had declined to care for this patient and RN#1 had declined to provide any further care for this patient. RN#2 explained that the agency has many nurses, but only 2 that cover the area where MR#1 resides. RN#2 stated that staffing is the main issue for MR#1's discharge. MR#2 further stated that the patient's physician was informed of the discharge and the physician would find another home care agency for the patient. The agency's policy titled, Discharge Planning (October 2010) states, "Patients will not be discharged without appropriate preparation. The patient's continuing care needs will be assessed on an ongoing basis, as well as at discharge. Information will be provided to assist the patient in planning his/her discharge, including referral and transfer." There was no indication that the patient's care needs had changed, there was no change in acuity or level of care, and no need for specialized services. The agency discharged the patient to suit their own lack of staffing and two nurses who desired to not provide care to a "difficult" patient. There was no documented evidence the agency followed their own policy to assist the patient with finding care with an alternate home care agency. There was no transfer of care to another agency.

Mistreatment, neglect or abuse CFR(s): 484.50(e)(1)(i)(B) (i)(B) Mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and/or misappropriation of patient property by anyone furnishing services on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on interview and record review, it was determined that the Agency failed to provide appropriate care and services and address a change in condition for 1 (MR #1) of 1 patient's record reviewed with a diagnosis of Hypertensive Chronic Kidney disease and pressure sores who required immediate management of an existing indwelling urinary catheter leak, resulting in the potential for the development of infection, worsening of pressure ulcers, psychological decline and unmet care needs, from a total of 4 sampled records reviewed. Findings include: A complaint on file alleged that the agency failed to provide immediate care for an indwelling urinary catheter (Foley) that became dislodged/disconnected and leaked urine onto the patient's wounds; and failed to treat the patient's change in condition. It was alleged that the agency was notified of the patient's change in condition and failed to provide immediate attention. Policy/Agency Admission packet document titled, "Call Us First" stated, "Global Home Care has an on-call nurse available 24 hours a day, seven days a week, to assist you based on your needs. We are always here for you! Please "Call Us First" for any concerns that you may have or for any immediate clinical needs." MR #1: The patient’s start of care (SOC) was 10/18/21 with diagnoses that included Hypertensive Chronic Kidney Disease, Congestive Heart Failure, Pressure Ulcers bilateral Buttocks, Neurogenic bladder, and Paraplegia (Paralysis). The clinical record review was conducted on 1/4/22 at 12:30 p.m. and revealed the following: The Initial Comprehensive Assessment dated 10/18/21, completed by the Clinical Manager (CM #1) indicated the patient was admitted with pressure sores to her bilateral buttocks and had an indwelling (Foley) urinary catheter. The assessment further revealed that the patient was partially paralyzed and totally dependent on others for grooming, dressing and toileting. The section that addressed caregiver availability indicated the patient lived alone in a senior apartment with daytime assistance. The Plan of Care (POC) ordered Skilled Nursing (SN) at a frequency of 2x/wk. x 1 wk., 1x/wk. x 8 wks. For disease management, complications of hypertensive heart and chronic kidney disease, wound care, and Foley care with instructions to (Change Foley Cath every month or PRN (as needed) using 22 Fr (catheter size) with 30cc balloon size, increase catheter one size PRN for leakage…” A review of the Skilled Nurses visit note dated 10/27/21 at 12:15 p.m., documented by the Registered Nurse (RN #1) stated, “Subjective Data: I’m paraplegic and that will never change (per patient), Impaired skin integrity related to pressure ulcers, Patient has a Foley Catheter which was changed…” There were no additional SN visit notes available for review. The next entry documented by RN #1 was a Discharge Oasis/Assessment dated 10/29/21 which documented, “Catheter-Foley, urine color: cloudy; Amount 1500ml (milliliters).” RN #1 further documented, “Patient will be discharge from home health services today. Patient very difficult to rendered [sic] care. Patient will look for another home care." There was no documented evidence that RN #1 assessed the patient’s catheter for leakage as reported. Additionally, there was no documented evidence that the patient declined further services or requested to be discharged from the agency’s services. A review of the agency’s complaint log revealed an entry dated 10/29/21 (date patient was discharged from the agency), entered by RN #2 which documented, “Patient was upset today and complained about the nurse (RN #1) not returning her call and wants the staff to go and visit her when she wants…, Spoke with Dr. (doctor), we are returning the patient to their office because no staff wants to take care of her anymore…” There was no documented evidence that agency staff followed up with the patient as requested to address the Foley catheter leak and change in condition. On 1/5/22 at 10:37 a.m., an interview was conducted with RN #2 who stated that she does marketing for the company and documents the complaints for the agency. During the interview, RN #2 stated that she is the person who documented the complaint based on what she was told by RN #1. RN #2 then stated, "She (patient) called the nurse late at night and wanted to see her right away but the nurse (RN #1) wasn't able to see her. She (patient) was demanding and difficult. I called her doctor, as I stated on the complaint form. We returned her to her doctor so they could find a new agency for her. We were this patient’s 4th home care agency.” When asked if she'd had an opportunity to speak with the patient directly regarding her concerns, RN #2 stated, "No. I just went by what I was told by the nurses." A review of the agency’s Communication Notes revealed the following: A note dated 10/27/21 documented by the Intake Coordinator (IC #1) stated, “RN #1 reported she just did a visit almost 2 hrs. (hour) visit, pt. (patient) is morbid obesity with wound at back. This is a hard case.” A note dated 10/29/21 stated, “RN #1 discharging as of today with visits.” A note dated 11/1/21, documented by the Administrator (Adm #1) stated, “Spoke to patient, she was noticeably upset. She understood that we discharged the case but (the patient) wanted a nurse to come out right away because she was experiencing a leak in her catheter. I restated that we were not able to meet her needs at this time and she could call her doctor regarding another home care agency…” There was no documented evidence that the agency staff or its administration provided needed assistance with the patient’s Foley catheter leakage as requested. An interview was conducted with Adm #1 and the Clinical Manager (CM #1) on 1/5/22 at 3:21 p.m. Adm #1 was queried about the conversation he had with the patient on 11/1/21 when the patient requested help in controlling her catheter leak. When asked if any immediate was provided by agency staff, Adm #1 responded, “I felt like I was being attacked by her words so there was nothing else I could do. CM #1 offered no response during the interview. Several requests were made to interview RN #1, however, after several attempts, the Administrator was unable to reach her and stated, "I tried but she hasn't returned any of my calls." The Agency neglected to provide care and services to address the immediate needs of the patient in light of the patient's indwelling catheter leakage, existing pressure sores and change in condition.

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 record review and interview, the agency failed to ensure the registered nurse conducted an initial assessment visit within 48 hours of referral for 1 of 4 (MR#1) records reviewed, resulting in delayed care and support needs for this patient. Findings include: MR#1: The patient was admitted to home care on 10/18/21 with diagnoses that included hypertensive chronic kidney disease, congestive heart failure, pressure ulcers on both buttocks, lack of bladder control due to a nerve condition, and paralysis of the lower legs and lower body. During record review on 1/4/22, it was noted that the agency received a form fax stamped on 10/1/21 titled, Continuing Patient Care (CPC), with physician orders for home care services for this patient. An agency communication note dated 10/4/21, indicates the patient called the agency office inquiring about orders and waiting for the registered nurse (RN) to call the patient and schedule a visit. The agency received another CPC form fax stamped on 1/11/21 with physician orders for home care for this patient. The start of care assessment (initial visit) was conducted by the Clinical Manager (CM#1, registered nurse) on 1/18/21, which was 17 days after the agency received the referral. There was no documentation to indicate the physician was informed of and approved of the 17-day delay in home care services for this patient. The findings were reviewed with and acknowledged by the Administrator (Adm#1) and CM#1 (clinical manager) during an interview on 1/5/21 at 3:20 p.m.

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 record review and interview, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19; and failed to develop a method of screening visitors and all staff employed by this agency, including those who were granted clinical privileges, resulting in the potential development and spread of a contagious viral infection between agency staff and the agency's 56 current patients (G684); and failed to provide documented evidence that Covid-19 infection control education and training was provided to all staff employed by the agency, including those who were granted clinical privileges, resulting in the potential for the development and spread of the Covid-19 infection to staff and all 56 patients currently serviced by this agency (G686). The cumulative effects of this systemic problem resulted in the Home Health Agency's inability to ensure the provision of quality health care in a safe environment for the Condition of Participation of 42 CFR 484.70 Infection Control.

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: Based on observation, interview and record review, the agency failed to maintain a coordinated agency-wide program for the surveillance, identification, and prevention of COVID-19; and failed to develop a method of screening visitors and all staff employed by this agency, including field staff who were granted clinical privileges, resulting in the potential development and spread of a contagious viral infection between agency staff and the agency's 56 current patients. Findings include: On 1/4/22 at 9:00 a.m., upon arrival to the agency, it was noted that there were no signage that instructed visitors on the protocol for entrance into the agency's suite. On 1/5/22 at 12:20 p.m., the agency's Administrator (Adm #1) and Clinical Manager (CM #1) were queried regarding the process or tool used for screening visitors upon entrance into the agency. Adm #1 acknowledged there was no process in place. When asked if there was a process in place for screening of field and office staff for potential COVID-19 infections, Adm #1 reported, "No." There was no evidence that visitors had been screened upon entrance into the agency. Further, there was no documented evidence that office staff had been screened, or that field staff had been screened for Covid-19 prior to the provision of care and services. Additionally, a request was made to review the agency's infection control surveillance logs for all patients and staff, and the infection control committee meeting minutes. Upon review of the requested data, the one surveillance log submitted addressed wound infections only. The above findings were discussed with and acknowledged by Adm #1 and CM #1 during an interview on 1/5/22 at 4:15 p.m.

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on interview and record review, it was determined the Agency failed to provide documented evidence that Covid-19 and Infection Control education and training had been provided to all staff employed by the agency including those who were granted clinical privileges, resulting in the potential for the development and spread of the Covid-19 infection to staff and all 56 patients currently serviced by this agency. Findings include: On 1/5/22 at 12:20 p.m., the Administrator (Adm #1) was queried about documentation of staff training, education, and in-services' regarding the Covid-19 virus. Adm #1 provided a binder titled, "Infection Control and In-Services." Upon review of the documents, that covered topics such as, Donning and Doffing PPE (Personal Protective Equipment), and printouts from CDC related to Covid-19. The documents had an attached sign in sheet which revealed staff's typed names with a check mark next to their names. There was no way to verify which, if any of the agency's staff had received training, in-services and education as per this requirement. There was no documented evidence that all staff received nor completed the required training on Covid-19 protocol. The Agency failed to provide infection control education to staff to prevent the probability of the development and spread of the Covid-19 virus. The above findings were reviewed with and acknowledged by Adm #1 during an interview on 1/5/22 at 4:15 p.m.

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 the registered nurse provided services at the frequency ordered by the physician for 1 of 4 (MR#1) records reviewed, resulting in the potential for a poor patient outcome for this patient. Findings include: MR#1: The patient was admitted to home care on 10/18/21 with diagnoses that included hypertensive chronic kidney disease, congestive heart failure, pressure ulcers on both buttocks, lack of bladder control due to a nerve condition, and paralysis of the lower legs and lower body. During record review on 1/4/22, it was noted that the 10/18/21 plan of care ordered the nurse to provide 2 visits in week one and then 1 visit each week for 8 weeks. The Clinical Manager (CM#1) provided the start of care visit on 10/18/21. There were no other nursing visits in week one. An agency communication note dated 10/21/21, indicates the patient called the office to ask for supplies and inquired who was her nurse. There was no indication that the patient had declined or delayed a nursing visit in week one. There was no documentation of a missed visit and no documentation that the physician was informed of and approved the change in the nursing visit frequency. The findings were reviewed with and acknowledged by the Administrator (Adm#1) and CM#1 during an interview on 1/5/21 at 3:20 p.m.

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 agency failed to ensure a discharge summary was sent to the primary care practitioner within 5 business days of the patient's discharge for 1 of 4 (MR#1) discharge records reviewed, resulting in the practitioner not having knowledge of the patient's health status, progress towards goals, or continuing health care needs at the time of discharge for this patient. Findings include: MR#1: The patient was admitted to home care on 10/18/21 with diagnoses that included hypertensive chronic kidney disease, congestive heart failure, pressure ulcers on both buttocks, lack of bladder control due to a nerve condition, and paralysis of the lower legs and lower body. During record review on 1/4/22, it was noted that the patient was discharged from the agency on 10/29/21. There was no documented evidence the agency ensured the physician was sent a discharge summary within 5 business days of discharge from the agency. The physician was not informed of the patient's health status at the time of discharge, progress towards goals, or likely continuing health care needs for this patient. The findings were reviewed with and acknowledged by the Administrator (Adm#1) and CM#1 (clinical manager) during an interview on 1/5/21 at 3:20 p.m. Adm#1 stated that discharge summaries are faxed to the physician. No evidence was provided for review by the time of the survey exit on 1/5/22 at 4:15 p.m.