Every finding on record at Good Shepherd Healthcare, LLC

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey on 11/14/24. The Agency was in compliance with the Condition, 42 CFR 484.22, Establishment of the Emergency Program for this survey.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 11/14/24. Standard level deficiencies cited. Abbreviations: AM = morning PM = afternoon/evening Pt./Pts. = Patient/Patients PT = Physical Therapist SN = Skilled Nurse SOC = Start of Care QAPI = Quality Assurance and Performance Improvement MD = Medical Doctor OASIS = Outcome and Assessment Information Set RN = Registered Nurse

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of the Error Summary report and staff interviews, it was determined that in 1 of 27 reports submitted for the last 12 months, the Agency failed to submit a timely report, resulting in a warning. Findings include: 1. The Error Summary report for 8/2023 to 7/2024, was reviewed on 11/13/24. The report included error # -3330 for 1 of 27 late submissions, which was 3.70 % of the OASIS reports submitted late, more than 30 days after the M0090. 2. During an interview with the Administrator Assistant on 11/14/24 at 9:15 AM, the Administrator Assistant confirmed that the error occurred.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, observation during home visits, clinical record reviews, and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./patient's representative information regarding the Administrator. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 11/12/24 at 10:50 AM. The folder lacked the Administrator’s name, address, and phone number to file a complaint and/or grievance. 2. The following home visits were conducted on 11/12/24: Pt. #1. SOC 9/27/24. Pt. #2. SOC 10/17/24. Pt. #3. SOC 10/12/24. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Administrator. 3. The following clinical records were reviewed on 11/12/24 and 11/13/24: Pt. #1. SOC 9/27/24. Pt. #2. SOC 10/17/24. Pt. #3. SOC 10/12/24. Pt. #4. SOC9/25/24. Pt. #5. SOC 7/19/24. Pt. #6. SOC 7/23/24. Pt. #7. SOC 7/10/24. The clinical records lacked documentation that the Pt./patient's representative was provided the name and contact of the Administrator to file a complaint or grievance. 4. During the entrance interview on 11/12/24 at 9:30 AM with the Assistant Administrator, Agency Supervisor, and the QAPI Coordinator; the Assistant Administrator stated the Administrator was hired 2 years ago. 5. During staff interviews with the Agency Supervisor/Director of Nursing, and the QAPI Coordinator on 11/13/24 at 11:05 AM and 2:15 PM, both confirmed the Agency failed to provide the Pt./patient’s representative information regarding the Administrator.

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 a review of clinical records, and staff interviews, it was determined in 6 of 7 (Pts. #1, 4, 6, 2, 3, and 7) clinical records reviewed, the Agency failed to ensure a referral was obtained to initiate service or that the initial assessment visit was done within 48 hours of receipt of the referral. 4. Pt. #2 was admitted to home health services on 10/17/24 with diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 11/13/24. The Face-to Face form signed by the APRN (Advanced Practice Registered Nurse) on 10/12/24 and received by the Agency on 10/12/24 that required: "Skilled Nursing Care and Physical Therapy for evaluation/assessment of rehab needs.” The record lacked a physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 11/13/24, the record lacked documentation the Agency initiated service within the required time frame. 5. Pt. #3 was admitted to home health services on 10/18/24 with diagnosis of Hemiplegia following Cerebral Infarction affecting right dominant side. The clinical record was reviewed on 11/13/24. The Face-to Face form signed by the Physician on 10/3/24 and received by the Agency on 10/3/24 the required: "Home Health Skilled Nursing Services.” The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 11/13/24, the record lacked documentation the Agency initiated service within the required time frame. 6. Pt. #7 was admitted to home health services on 7/10/24 with diagnosis of Bilateral Primary Osteoarthritis of Knee. The clinical record was reviewed on 11/13/24. The Face-to Face form signed by the Physician on 6/16/24 and received by the Agency on 6/16/24 that required: "Skilled Nursing Care and Physical Therapy for evaluation/assessment of rehab needs.” The record lacked a Physician ordered SOC date or documentation the Pt. was discharged from an inpatient facility. As of 11/13/24, the record lacked documentation the Agency initiated service within the required time frame. 7. During an interview with the Assistant Administrator, Agency Supervisor/ Director of Nursing, and QAPI Coordinator on 11/13/24 at 11:05 AM and 2:30 PM; the administrative team confirmed the initial assessment was not done within the time frame requirement. Findings include: 1. Pt. #1 was admitted to home health services on 9/27/24 with the diagnosis of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. The clinical record was reviewed on 11/12/24. The record contained a referral that was faxed from the physician’s office to the Agency on “9/16/2024”. The “OASIS-E Start of Care” assessment form was completed by the SN on “9/27/2024. As of 11/12/24, the record lacked documentation of an inpatient facility stay, physician ordered SOC date, and that the Agency initiated service within 48 hours after the referral was received. 2. Pt. #4 was admitted to home health services on 9/25/24 with the diagnosis of Type 2 Diabetes Mellitus without Complications. The clinical record was reviewed on 11/13/24. The record contained a referral that was faxed from the physician’s office to the Agency on “9/16/2024”. The “OASIS-E Start of Care” assessment form was completed by the SN on “09/25/2024”. As of 11/13/24, the record lacked documentation of an inpatient facility stay, physician ordered SOC date, and that the Agency initiated service within 48 hours after the referral was received. 3. Pt. #6 was admitted to home health services on 7/23/24 with the diagnosis of Hypertensive Heart Disease with Heart Failure. The clinical record was reviewed on 11/12/24. The record contained a referral that was faxed from the physician’s office to the Agency on “06/26/2024”. The OASIS-E Start of Care” assessment form was completed by the SN on “07/23/2024”. As of 11/12/24, the record lacked documentation of an inpatient facility stay, physician ordered SOC date, and that the Agency initiated service within 48 hours after the referral was received.

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, observation during home visits, clinical record reviews, and staff interviews, it was determined that in 7 of 7 (Pts. #1, 2, 3, 4, 5, 6, and 7) clinical records reviewed, the Agency failed to provide the Pt./patient's representative information regarding the Agency Supervisor/Director of Nursing. Findings include: 1. The Agency’s Pt. admission folder was reviewed on 11/12/24. The folder lacked the name and information to contact the Agency Supervisor/Director of Nursing. 2. The following home visits were conducted on 11/12/24: Pt. #1. SOC 9/27/24. Pt. #2. SOC 10/17/24. Pt. #3. SOC 10/12/24. During the home visits, the Pt. admission folders were observed, and lacked the name and contact information of the Agency Supervisor/Director of Nursing. 3. The following clinical records were reviewed on 11/12/24 and 11/13/24: Pt. #1. SOC 9/27/24. Pt. #2. SOC 10/17/24. Pt. #3. SOC 10/12/24. Pt. #4. SOC9/25/24. Pt. #5. SOC 7/19/24. Pt. #6. SOC 7/23/24. Pt. #7. SOC 7/10/24. The clinical records lacked documentation that the Pt./patient's representative was provided the name and contact of the Agency Supervisor/Director of Nursing. 4. During the entrance interview on 11/12/24 at 9:30 AM with the Assistant Administrator, Agency Supervisor, and the QAPI Coordinator; the Assistant Administrator stated the Agency Supervisor/Director of Nursing was hired 2 years ago. 5. During staff interviews with the Agency Supervisor/Director of Nursing, and the QAPI Coordinator on 11/13/24 at 11:05 AM and 2:15 PM, both confirmed the Agency failed to provide the Pt./patient’s representative information regarding the Agency Supervisor/Director of Nursing.

Recertification survey completed. Standard level deficiencies cited.

EP Testing Requirements CFR(s): 484.102(d)(2) *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d) (2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility- based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. This STANDARD is not met as evidenced by: A. Based on a review of the Agency's Emergency Preparedness Plan, review of Agency's policy and staff interview, it was determined that the Agency failed to ensure that the Agency conducted testing of the Emergency Preparedness to ensure the effectiveness of the Agency's Emergency Preparedness Plan. Findings Include: 1. The Agency's Emergency Preparedness Plan was reviewed on 09/23/2021 at 9:30 AM. The Emergency Preparedness Plan failed to include documentation indicating that the Agency conducted any testing exercise or drills since 2018. 2. The Agency's policy titled " Emergency Management Plan" was reviewed on 09/23/2021 at 10:00 AM. The policy required..."Procedure...Testing:..1..Good Shepherd Healthcare will test the emergency management plan, at each site included in the plan, at least every two (2) years, either in response to an actual emergency or in a planned exercise." 3. During an interview with the Administrator and the Director of Nursing on 09/23/2021 at 11:30 AM. The Administrator confirmed that the Agency has not conducted testing of the Emergency Preparedness after 2018.

Recertification survey completed. Standard level deficiencies cited.