Every finding on record at Good Health Services Inc.

Purpose of Visit: Recertification Inspection Entrance Date: 09/29/2021 An entrance conference was conducted with the agency Adm at 12:45 p.m. The Adm was informed that the purpose of the survey was for a 36-month recertification inspection. L&C Census: 12 Exit Date: 10/04/2021 An exit conference was conducted at 2:00 p.m. with the Adm and DON. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional documentation. Additional documentation was not provided. The agency was informed that if violations were cited, the agency would receive the Statement of Deficiencies within 10 business days post exit. Written instructions were provided for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. The agency was in substantial compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies. Abbreviation List: L & C- Licensed and Certified Adm-Administrator DON-Director of Nurses/Supervising Nurse CFR-Code of Federal Regulations

Purpose of Visit: Recertification Inspection Entrance Date: 09/29/2021 An entrance conference was conducted with the agency Adm at 12:45 p.m. The Adm was informed that the purpose of the survey was for a 36-month recertification inspection. L&C Census: 12 Exit Date: 10/04/2021 An exit conference was conducted at 2:00 p.m. with the Adm and DON. The preliminary findings were discussed. The agency was given an opportunity to ask questions and provide additional documentation. Additional documentation was provided, agency infection control report. The agency was informed that if violations were cited, the agency would receive the Statement of Deficiencies within 10 business days post exit. Written instructions were provided for how to submit an acceptable plan of correction, within 10 days of receipt of the Statement of Deficiencies. The agency met conditions of participation. Abbreviation List: L & C- Licensed and Certified Adm-Administrator Alt Adm - Alternate Administrator DON - Direction of Nurses (Supervising Nurse) ADON - Alternate Director of Nurses LVN - Licensed Vocational Nurse NOMNC- Notice of Medicare Non-Coverage POC- Plan of Care SOC- Start of Care HHA- Home Health Agency CFR-Code of Federal Regulations PIP- Performance Improvement Projects EHR-Electronic Health Record QAPI-Quality Assessment Performance Improvement OASIS -outcome and assessment information set SN- Skilled Nursing Registered Nurse (RN) CMS- Center for Medicare and Medicaid Services COVID-19- Novel Coronavirus Disease 2019 QIO-Quality Improvement Organization

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to respect the patient's right to receive proper written notice, in advance of terminating on-going care in four (Patients #6, 7, 8 and 9) of four inactive patient records reviewed. The agency failed to provide the Centers for Medicare and Medicaid form titled "Notice of Medicare Non-Coverage". The failure could place the patients at risk of harm due to inadequate or inappropriate continuity of care in the patients' post-discharge needs and could prevent the patients from exercising the right to appeal the discharge decision, if desired. FINDINGS INCLUDED: Clinical Record #6: Record review 10/012021. Record review of the clinical for Patient #6 revealed a POC for the certification period of 08/22/2021 to 10/20/2021 with a SOC date of 11/01/2019 and was completed by the DON. Patient #6's record included a discharge OASIS that was digitally signed by the DON and dated 08/31/2021. Patient #6's clinical record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 08/31/2021. The record did not include a written NOMNC. Clinical Record #7: Record review 10/012021. Record review of the clinical for Patient #7 revealed a POC for the certification period of 05/17/2021 to 07/15/2021 with a SOC date of 11/18/2020 and was completed by the DON. Patient #7's record included a discharge OASIS that was digitally signed by the DON and dated 07/01/2021. Patient #7's clinical record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 07/01/2021. The record did not include a written NOMNC. Clinical Record #8: Record review 10/012021. Record review of the clinical for Patient #8 revealed a POC for the certification period of 12/01/2020 to 01/29/2021 with a SOC date of 08/03/2020 and was completed by the DON. Patient #8's record included a discharge OASIS that was digitally signed by the DON and dated 12/29/2020. Patient #8's clinical record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 12/29/2020. The record did not include a written NOMNC. Clinical Record #9: Record review 10/012021. Record review of the clinical for Patient #9 revealed a POC for the certification period of 06/25/2021 to 08/23/2021 with a SOC date of 04/26/2021 and was completed by the DON. Patient #9's record included a discharge OASIS that was digitally signed by the DON and dated 07/12/2021. Patient #9's clinical record did not show that the patient or patient representative received a proper written notice of intent to discharge no later than two days in advance of terminating on-going care on 07/12/2021. The record did not include a written NOMNC. In an interview on 10/04/2021 at approximately 1:15 p.m. with the Adm and the DON, the surveyor discussed the above findings of why the agency had not provided written notice of the intent to discharge with the NOMNC form no later than two days in advance of terminating on-going care for Patients #6, 7, 8 and 9. The Adm replied, "I thought it was only for goals met." Review of agency policy titled "Patient/Client Transfer and Discharge Notices" revised 080120 read in part "...Policy III. The Agency will deliver the Notice of Medicare Non-Coverage...to the patient/client (or authorized representative), at least two...calendar days before Medicare covered services end or the second to the last day of service if care is not provided daily...II...A. Agency staff will provide valid delivery notice (involves both delivery and completion) of the NOMNC...even if the patient/client agrees with the discharge...C. If the Agency fails to give valid notice, patient/client coverage continues for at least two...days after the notice is received...E. The notice may not be routinely delivered at the time services begin...I. The Agency will have the patient/client... representative complete and sign the NOMNC..."

Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient's condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview the agency failed to ensure the patient's individualized plan of care was reviewed by the patient's physician no less than once every 60 days, beginning with the start of care date in three (Clinical Records # 2, # 3 and # 5) of five active clinical records reviewed. The failure could place the patients at risk of not having physician oversight of care and treatment and not having an individualized plan of care developed in the required timeframe. FINDINGS INCLUDED Clinical Record #2: Record review of the clinical record for Patient # 2 contained a POC for the certification period of 07/15/2021 to 09/22/2021. The POC included a start of care date of 09/28/2020 with a primary diagnosis of heart failure. The POC was signed by the DON and dated 07/23/2021. The POC contained an order for SN visits one time per week for nine weeks and one to two as needed visits. The record did not contain a completed reassessment POC beginning with 09/23/2021. On 09/30/2021 at 11:00 a.m. the surveyor requested the updated POC for Patient # 2. The Adm replied, "It's not completed." Clinical Record #3: Record review of the clinical record for Patient #3 contained a POC for the certification period of 07/29/2021 to 09/26/2021. The POC included a start of care date of 12/21/2020 with a primary diagnosis of bilateral primary osteoarthritis of knee. The POC was signed by the DON and dated 07/28/2021. The POC contained an order for SN visits one time per week for eight weeks and one to two as needed visits, effective 08/01/2021 and ending 09/25/2021. The record did not contain a completed reassessment POC beginning with 09/27/2021. On 09/30/2021 at 11:25 a.m. the surveyor requested the updated POC for Patient #3. The Adm replied, "It's under review." Clinical Record #5: Record review of the clinical record for Patient #5 contained a POC for the certification period of 07/28/2021 to 09/25/2021. The POC included a start of care date of 03/30/2021 with a primary diagnosis of bilateral primary osteoarthritis of knee. The POC was signed by the DON and dated 07/27/2021. The POC contained an order for SN visits one time per week for eight weeks and one to two as needed visits, effective 08/01/2021. The record did not contain a completed reassessment POC beginning with 09/26/2021. On 09/30/2021 at 11:25 a.m. the surveyor requested the updated POC for Patient #5. The Adm replied, "It's under review." Patients #, 2, 3 and 5's clinical records did not show that they had a current and completed individualized plan of care that was reviewed by the patients physicians no less than once every 60 days. An interview was conducted with the Adm and DON on 10/04/2021 at approximately 1:15 p.m. The surveyor discussed the above findings of why Patients # 2, 3 and 5's clinical records did not contain completed current POC(s) on 09/30/2021 (no less than once every 60 days). The DON stated that she just had not completed the POCs. Review of agency policy titled "Plan of Care" revised 11/01/20 read in part: " ...VI. The individualized plan of care must be reviewed and revised by the physician and/or non-physician practitioner who is responsible for the home health plan of care and the Agency as frequently as the patient's/client's condition or needs require, but no less frequently than once every sixty (60) days, beginning with the start of care date ...."

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, in one of one agency QAPI program, the agency failed to conduct PIP(s) for the calendar years 2018, 2019 and 2020 that reflected the scope, complexity and past performance of the agency's services and operations. The failure could place the agency at risk of not improving and providing quality care and services to the agency's patients. FINDINGS INCLUDED: During the entrance conference on 09/29/2021 at approximately 12:45 p.m., the surveyor requested all agency QAPI/documents/reports/binders. Record review of the agency's QAPI records did not reveal any reports, reviews or documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements, for the years 2018, 2019 and 2020. On 09/29/2021 the surveyor also reviewed the agency's business profile binder. The binder also did not reveal any reports, reviews or documentation that indicated the agency had conducted PIP(s) per federal regulatory requirements, for the years 2018, 2019 and 2020. During an interview on 10/04/2021 at 1:00 p.m., with the Adm and the DON the surveyor discussed the above findings of why the agency had not ensured that the agency had conducted PIP(s) per federal regulatory requirements, for the years 2018, 2019 and 2020. The Adm stated that the agency was not aware of the regulatory requirement. Review of agency policy titled "Quality Assurance Performance Improvement Program" revised 011318, read in part: " ...D. Performance improvement projects 1. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency's services and operations. 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects ..."