Every finding on record at Goodhope Healthcare & Home Health Svcs Inc

The Emergency Preparedness requirements were evaluated in conjunction with the recertification survey on 02/09/24. Standard level deficiencies cited.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop 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: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness plan and Staff interview, it was determined the Agency failed to review and update its Emergency Preparedness plan. This has the potential to affect all Patients who receive services from the Agency. Findings include: 1. The Agency’s undated Emergency Preparedness Plan was reviewed on 02/06/24. The Emergency Preparedness Plan lacked a date, indicating when the plan was last reviewed and updated. 2. During an interview with the Clinical Manager on 02/08/24 at 11:00 AM, the Clinical Manager confirmed the Agency failed to review and update the Emergency Preparedness plan.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on a review of the Agency’s Emergency Preparedness Plan and Staff interview, it was determined the Agency failed to ensure the Plan was established based on an updated risk assessment using an all-hazards approach. Findings include: 1. The Agency’s undated Emergency Preparedness Plan was reviewed on 02/06/24. The Plan included a “Hazard Vulnerability Assessment.” The assessment lacked a date to indicate when the plan was last reviewed based on an updated hazard vulnerability assessment. 2. During an interview with the Clinical Manager on 02/08/24 at 11:00 AM, the Clinical Manager stated that the Hazard Vulnerability Assessment should be updated yearly and confirmed that it was not updated, as required.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on review of the Agency’s Emergency Preparedness Plan and Staff interview, it was determined the Agency failed to ensure the communication plan included an accurate list of Staff, patient physicians, contracted staff and their contact information. Findings include: 1. The Agency's undated Emergency Preparedness plan was reviewed on 02/06/24. The plan contained an undated Agency staff list which contained names of multiple staff that had left the Agency. As of 02/08/24, the communication plan lacked a list of current Staff, Patient physicians, contracted staff and their contact information. 2. During an interview with the Clinical Manager on 02/08/24 at 11:00 AM, the Clinical Manager confirmed the communication plan lacked an accurate list of staff, contracted staff, Patient Physicians and their contact information.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and 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 PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization 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 PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE 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 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 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 PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE'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 HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a 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 every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA 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 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 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 HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA'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. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on a review of the Agency's Emergency Preparedness plan and staff interview, it was determined the Agency failed to conduct emergency exercises as required. This has the potential to affect all Patients who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness plan was reviewed on 02/06/24. As of 02/08/24, the Agency lacked documentation the Agency conducted any exercises in 2021, 2022 and 2023, pertaining to the Agency's Emergency Preparedness plan. 2. During an interview with the Clinical Manager on 02/08/24 at 11:00 AM, the Clinical Manager confirmed the Agency was unable to provide documentation that the Agency conducted emergency exercises as required.

Recertification survey completed on 02/09/24. Standard level deficiencies cited.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on observation and staff interview, it was determined that the Agency failed to ensure the Administrator maintained responsibility of the day to day operations. This has the potential to affect all patients receiving services from the Agency. Findings include: 1. On 02/06/24 at 9:40 AM, it was observed that the Agency’s posted operating hours were from 9:00 AM to 5:00 PM. The office was closed until the Clinical Manager arrived at 10:30 AM. She stated she was the Alternate Administrator. At 12:30 PM the Clinical Manager had to leave the office for the remainder of the day. There was no administrative or clinical staff at the office to assist with surveyor access to clinical records, personnel files, in-service records or policies and procedures after 12:30 PM. The Administrator failed to maintain day to day operations. 2. On 02/09/24 at 10:00 AM, it was observed the Clinical Manager left early for the remainder of the day. The Agency lacked an available administrator or alternate administrator to conduct day to day operations after 10:00 AM. 3. During the interview with the Clinical Manager on 02/09/24 at 10:00 AM, the Clinical Manager confirmed that the Administrator and Alternate Administrator were unavailable to continue with the day to day operations of the Agency.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on on-site observations and a Staff interview, it was determined the Agency failed to ensure a Clinical Manager was available during all operating hours. Findings include: 1. On 02/06/2024 at 12:15 PM, It was observed that the Clinical Manager had to leave for the day. The Alternate Clinical Manager (Employee #4) was not available. It was observed that on 02/06/24 at 12:15PM, the clinical manager and her alternate were unavailable during the agency's operating hours of 12:15 PM to 5:00 PM. 2. It was also observed on 02/09/24 the Clinical Manager left at 10:00AM and no other administrative or clinical staff were available on-site during operating hours. 3. The above findings were confirmed during the interview with the Clinical Manager on 02/09/24 at 10:00 AM.

Establishment of the Emergency Program (EP) CFR(s): 484.102 The [facility, except for Transplant Programs] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] 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: *[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: . A. Based on review of the Emergency Preparedness Plan/Policies, Agency Inservices binder, and Staff interview, it was determined the Agency failed to review and update its Emergency Plan and policies biannually; and failed to provide Emergency Preparedness staff training and testing of the Emergency Plan. This has the potential to affect all pt.s receiving services from the Agency. Findings Include: 1. The Agency failed to review and update its Emergency Plan and policies biannually (E0004). 2. In 5 of 6 personnel files reviewed, the Agency failed to provide Emergency Preparedness staff training and testing of the Emergency Plan (E0036). The cumulative effect of these systemic practices resulted in the Agency's inability to provide appropriate direction or supervision in the event of an emergency or disaster.

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop 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: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. This STANDARD is not met as evidenced by: . A. Based on review of the Agency's Emergency Preparedness Plan and staff interview, it was determined the Agency failed to review and update its Emergency Plan and policies biannually. This has the potential to affect all Pts. who receive services from the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 3/10/21 at 9:15 AM. This plan was titled "Emergency Operational Plan." The Plan the plan lacked documentation when it was last reviewed. 2. During an interview with the Director of Nursing on 3/10/21 at 2:45 PM, the Director of Nursing confirmed the above finding.

EP Training and Testing CFR(s): 484.102(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, 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 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: . A. Based on review of the Agency's Emergency Preparedness Plan, personnel file review, review of in-services binder, policy review and staff interview, it was determined the Agency failed to provide Emergency Preparedness staff training and testing of the Emergency Plan. This has the potential to affect all Pts. served by the Agency. Findings include: 1. The Agency's Emergency Preparedness Plan was reviewed on 3/10/21 at 9:15 AM. This plan lacked documentation showing the Agency conducted staff training of emergency preparedness procedures upon orientation or biannually. The Agency was also unable to provide documentation that full scale or tabletop testing exercises have been conducted after 12/8/2017. 2. The following personnel files were reviewed on 3/10/21 at 9:30 AM: E3 ( HHA), DOH: 10/9/20. E5 (PT), DOH:2/10/21. E6 (PT), DOH:1/2/19. E7 (PT), DOH:10/20/19. The above files reviewed all lacked Emergency Preparedness training and testing. 3. The Agency's In-services Binder and the Emergency Management Plan were reviewed on 3/10/21 at 10:00 AM. The in-services binder lacked documentation the Agency provided any Emergency Preparedness staff training in-services and the Agency's Emergency Management Plan binder lacked documentation that a full scale or tabletop exercise have been conducted after 12/8/2017. 4. The Agency "All Hazards Home Health Agency Emergency Operational Plan (EOP) was reviewed on 3/10/21 at 10:15 AM. The EOP documents under Drills: " ...Agency staff members will participate in an annual emergency response drill to an actual event or a simulation of event. The Agency will activate the EOP once a year as an emergency response exercise to an accrual emergency or in a planned exercise at the primary location of the office ....." 5. During an interview with the Director of Nursing on 3/10/21 at 2:45 PM, the Director of Nursing confirmed the above findings

Substantial Allegation Survey conducted for complaint #2021057/IL 00128599 on 3/1/21. Recertification with a Full Extended Survey Conducted from 3/8/21 to 3/11/21. A Focused Infection Control survey (FIC) was conducted on 3/11/21. Standard level deficiencies cited. 42 CFR 484.80(f)(3): Eligible training and competency evaluation organizations. Determination has been made that this Agency is not in compliance with the Conditions of Participation for: 42 CFR 484.60 Care Planning, Coordination of Services, and Quality of Care. 42 CFR 484.102 Emergency Preparedness. Therefore, the Agency is precluded from conducting aide training and/or competency evaluations for 24 months effective 3/11/21. This applies even if the Agency is not currently conducting aide training and/or competency evaluation. Abbreviations: # = number () greater than cm = centimeters SN = Skilled Nurse POC = Plan of care SOC = Start of care PsOC = Plans of Care RN = Registered Nurse PM = afternoon/evening Pt./ Pts. = Patient/Patients DON = Director of Nursing HHA= Home Health Aide PT= Physical Therapist

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: . A. Based on a review of clinical records, policy review and staff interview, it was determined the Agency failed to ensure the discharge instructions were completed relative to care and services required after discharge, and inform the Physician of the Agency's plan to discharge services. This was found in 1 of 3 (Pt. #1) closed clinical records reviewed. Findings include: 1. Pt. #1. SOC 10/9/20. Diagnoses: Unspecified Severe Protein-Calorie Malnutrition, Unspecified Stage Pressure Ulcer of Sacral Region and Unspecified Stage Pressure Ulcer of Other Site. The clinical record was reviewed on 3/1/21 at 1:15 PM. The record contained documentation the Agency provided SN and Home Health Aide services from 10/9/20 to 11/22/20. The SN visit note dated 11/22/20 included documentation the Pt. had the existence of 3 wounds (sacral, left and right posterior legs). The "Discharge Summary" form completed by the RN on 1/23/21 included: "Reason for Discharge - Transferred to another HHA... Narrative - Patient has...pressure ulcer not healing patient need higher level of care, needs services 24/7, home health can not deliver." The Discharge Summary form also included a section titled "Transfer Discharge Instructions", this section was left blank. As of 3/1/21, the record lacked any discharge instructions for the Pt./family or for other health care Agency to provide care to Pt. #1 after the Agency's discharge on 11/24/20. The record also lacked documentation the Physician was informed of the Agency's decision to discharge Pt. #1. 2. The Agency policy titled, "Discharge Process" was reviewed on 3/1/21 at 2:20 PM. The policy required: "For a patient requiring continuing care, assistance will be given to the patient and family/caregiver in order to manage continuing care needs after the organization's services are discontinued. Discharge instructions will be provided. a. Discharge planning will identify ongoing needs the patient may have. b. Arrangements for such services will be coordinated by the organization, when applicable..." 3. During an interview with the DON on 3/1/21 at 1:55 PM, the DON stated this Agency could no longer provide the type of care the Pt. required, and the family decided to obtain care and services from a different Agency. During the interview, an inquiry was made whether the Physician was informed regarding this issue, the DON responded, "No, I don't think I called the doctor..." 4. During an interview with the DON on 3/1/21 at 1:55 PM and 3/4/21 at 10:36 AM, the DON confirmed the Agency failed to complete discharge instructions regarding the care and services required for Pt. #1, and inform the Physician of the Agency's plan to discharge Pt. #1.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: . A. Based on staff interview, Agency policy review, and clinical record review, it was determined the Agency failed to investigate and document Pt./family complaints/grievances. This was found in 2 of 3 (Pts. #1 and 2) closed clinical records reviewed . Findings include: 1. During the entrance interview with the DON on 3/1/21 at 10:15 AM, a request was made to review documentation pertaining to complaints/grievances the Agency had received in 2020. The DON stated, "We had one complaint last year involving Pt. #1 and Pt. #2. I handled the complaints. I did not write it...it was about..." As of 3/1/21, the Agency lacked documentation regarding the nature of the complaint, the investigation and follow-up with the Pt. and/or complainant. 2. Pt. #1. SOC 10/9/20. Diagnoses: Unspecified Severe Protein-Calorie Malnutrition, Unspecified Stage Pressure Ulcer of Sacral Region and Unspecified Stage Pressure Ulcer of Other Site. The clinical record was reviewed on 3/1/21 at 1:15 PM. The record lacked documentation of any Pt./family concerns and/or complaints. During an interview with the DON on 3/1/21 at 10:15 AM, the DON stated a Pt./family complaint was received regarding care and/or services for Pt. #1. The DON stated received the complaint, and failed to document the nature and investigation of this complaint. 3. Pt. #2. SOC 4/6/20. Diagnoses: Unspecified Atrial Fibrillation and Multiple Sites Muscle Wasting and Atrophy. The clinical record was reviewed on 3/1/21 at 11:30 AM. The record lacked documentation of any Pt./family concerns and/or complaints. During an interview with the DON on 3/1/21 at 10:36 AM, the DON stated received a Pt./family complaint regarding skilled care verses custodial care for Pt. #2. The DON stated failed to document the nature and investigation of this complaint. 4. The Agency's policy titled, "Client Rights and Responsibilities Statement" was reviewed on 3/1/21 at 2:10 PM. The policy required: "...The right to have complaints addressed and resolved in a timely manner and to have the Grievance Procedure reviewed by a staff member..." 5. The Agency's policy titled, "Complaint Resolution Process" was reviewed on 3/1/21 at 2:15 PM. The policy required: "1. If conflicts arise between client and staff in the decision-making process of planning for care or treatment, all attempts will be made to resolve such conflicts with the individual and/or team providing the care or services to the client... 12. A final decision will be rendered and the client will receive the written notification of the decision within a timeframe no longer than 10 business days." 6. During an interview with the DON on 3/4/21 at 10:36 AM, the DON confirmed the Agency did receive several complaints last year (2020). Including the complaints of Pts. #1 and 2 and failed to document the nature, investigation and follow-up of the complaints.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: . A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure care was provided as indicated in the POC; failed to ensure the POC included treatment for wound(s); failed to ensure the Agency assessed the need for Pneumoccal Pneumonia and/or Influenza Vaccine; failed to ensure verbal orders were reviewed by the physician, within 30 days, as required by Agency policy; failed to ensure the Physician was notified regarding changes in the patient's condition that may warrant a change in the POC; and failed to ensure discharge plans were communicated to the Pt./family and the Physician prior to the Agency's discharge. This has the potential to affect all Pts. receiving services. Findings include: 1. In 2 of 8 clinical records reviewed, the Agency failed to ensure the POC included treatment for wound(s) (G-574). 2. In 3 of 8 clinical records, the Agency failed to ensure care was provided as indicated in the POC (G-580). 3. In 5 of 5 active clinical records, the Agency failed to ensure the Agency assessed the need for Pneumococcal Pneumonia and/or Influenza Vaccines (G582). 4. In 1 of 5 active clinical records, the Agency failed to ensure verbal orders were reviewed by the physician, within 30 days, as required by Agency policy (G584). 5. In 2 of 3 closed clinical records, the Agency failed to ensure the Physician was notified regarding changes in the patient's condition that may warrant a change in the POC (G590). 6. In 2 of 3 closed clinical records, the Agency failed to ensure discharge plans were communicated to the Pt./family and the Physician, prior to the Agency's discharge (G598). The cumulative effect of these systemic practices resulted in Agency's inability to provide care effectively and ensure patients received the care and services as required on the PsOC.

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: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the POC included treatment for wound(s). This was found in 2 of 3 (Pt. #3 and #8) clinical records reviewed, wherein the Pt. required wound care. Findings include: 1. Pt. #3. SOC 3/6/20. Primary Diagnosis: Subsequent Encounter Burn of Third Degree of Left Thigh. The clinical record was reviewed on 3/1/20 at 12:30 PM. The record contained the SOC comprehensive assessment dated 3/6/20 which included a description of the wound care provided to the left thigh: "Clean with normal saline, apply petroleum jelly to wound bed, cover with dry gauze, secure with tape". The SN visit note dated 3/9/20 included: "...left thigh...Wound cleaned with wound cleaner, apply moisturizer, cover with dry gauze." The POC effective 3/6/20 lacked the description of the wound care for the left thigh as provided by the SN. As of 3/1/21, the record lacked any addendums to the POC. 2. Pt. #8. SOC 01/23/20. Diagnoses: Site Not Specified Urinary Tract Infection and Stage 3 Pressure Ulcer of Right Buttock. The clinical record was reviewed on 3/9/21 at 4:00 PM. The record contained the SN visit note dated 1/14/21 which included documentation the SN provided wound care to the Stage 3 Right Buttock Pressure Ulcer: "cleaned with wound cleanser, apply and covered with mepilex borders." The POC for the certification period of 11/18/20 to 1/16/21 lacked wound care instructions for the Stage 3 Right Buttock Pressure Ulcer. The POC lacked any goals, rehabilitation potential, discharge plan, homebound narrative, medical necessity and admission narrative for Pt. #8, as required by the Agency's POC form. 3. During an interview with the DON on 3/4/21 at 10:36 AM, the DON confirmed the Agency failed to ensure the POC included treatment for left thigh wound.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure care was provided as indicated in the POC. This was found in 3 of 8 (Pts. #1, #2 and #8) clinical records reviewed. Findings include: 1. Pt. #1. SOC 10/9/20. Diagnoses: Unspecified Severe Protein-Calorie Malnutrition, Unspecified Stage Pressure Ulcer of Sacral Region and Unspecified Stage Pressure Ulcer of Other Site. The clinical record was reviewed on 3/1/21 at 1:15 PM. The record contained the POC for the certification period of 10/9/20 to 12/7/20 requiring: "SN to perform pressure ulcer care to sacral, left leg posterior, right leg posterior. Cleanse wound with normal saline apply calcium alginate to all wounds, cover and secure with gauze pad, apply ABD pad and secured with tape..." The SN/RN visit notes dated 10/16/20, 10/18/20, 10/29/20, 11/1/20, 11/5/20, 11/10/20, 11/12/20 and 11/17/20 included: "Wound cleaned with normal saline applied wet to dry dressing, cover with gauze daily..." The RN failed to provide wound care as identified in the POC effective 10/9/20. The record lacked any addendums to the POC. 2. Pt. #2. SOC 4/6/20. Diagnoses: Unspecified Atrial Fibrillation and Multiple Sites Muscle Wasting and Atrophy. The clinical record was reviewed on 3/1/21 at 11:30 AM. The record contained the POC for the certification period of 4/6/20 to 6/4/20 requiring: "Notify Physician of vital sign parameters out of range... Systolic BP: Greater Than (>) 160 Less Than (90) - Diastolic BP: Greater Than (>) 90 Less Than () 5." The SN visit notes dated 1/20/21, 2/17/21 and 2/24/21 lacked documentation the SN assessed the Pt. for pain. 3. During an interview with the DON on 3/4/21 at 10:36 AM, the DON confirmed the Agency failed to ensure the RN provided care, as indicated in the POC.

Influenza and pneumococcal vaccines CFR(s): 484.60(b)(2) Influenza and pneumococcal vaccines may be administered per agency policy developed in consultation with a physician, physician assistant, nurse practitioner, or clinical nurse specialist, and after an assessment of the patient to determine for contraindications. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records and staff interview, it was determined the Agency failed to ensure the Agency assessed the need for Pneumococcal Pneumonia and/or Influenza vaccines. This was found in 5 of 8 (Pts. #4, 5, 6, 7 and 8) clinical records reviewed. Findings Include: 1. The following clinical records were reviewed from 3/9/21 to 3/10/21 from 11:00 AM to 10:00 AM. Pt. #4. SOC 2/16/21. Lacked an Influenza and Pneumococcal Pneumonia inquiry Pt. #5. SOC 1/8/21. Lacked an Influenza and Pneumococcal Pneumonia inquiry Pt. #6. SOC 3/3/21. Lacked an Influenza and Pneumococcal Pneumonia inquiry Pt. #7. SOC 2/1/20. Lacked an Influenza and Pneumococcal Pneumonia inquiry. Pt. #8. SOC 1/23/20. Lacked an Influenza and Pneumococcal Pneumonia inquiry. 2. During an interview with the DON on 3/10/21 from 1:30 PM to 4:30 PM, the DON stated, the RN is required to assess the patient's Influenza and Pneumococcal Pneumonia vaccination status at the SOC, and this information is documented in SOC comprehensive assessment. During the same interview, the DON confirmed the SOC comprehensive assessment/clinical record lacked an inquiry for the Pneumococcal Pneumonia and Influenza vaccines.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure verbal orders were reviewed by the Physician within 30 days, as required by the Agency policy. This was found in 1 of 5 (Pts. #8) active clinical records reviewed. Findings include: 1. Pt. #8. SOC 01/23/20. Diagnoses: Site Not Specified Urinary Tract Infection and Stage 3 Pressure Ulcer of Right Buttock. The clinical record was reviewed on 3/9/21 at 4:00 PM. The record contained the Physician Order dated 1/15/21 requiring the Agency to continue services after 1/16/21. As of 3/9/21, the Physician Order lacked the Physician's signature, verifying the Physician reviewed and approved the Physician/verbal order. 2. The Agency policy titled, "Verbal Orders" was reviewed on 3/10/21 at 4:10 PM. The policy required: "...5. All entered verbal order must be signed by the physician". 3. During an interview with the Director of Nursing on 3/10/21 from 1:30 PM to 4:00 PM, the Director of Nursing the verbal orders indicated above lacked the Physician's signature, as required by the Agency.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure the Physician was notified regarding changes in the patient's condition that may warrant a change in the POC. This was found in 2 of 3 (Pts.# 1 and 3) closed clinical records reviewed. Findings include: 1. Pt. #1. SOC 10/9/20. Diagnoses: Unspecified Severe Protein-Calorie Malnutrition, Unspecified Stage Pressure Ulcer of Sacral Region and Unspecified Stage Pressure Ulcer of Other Site. The clinical record was reviewed on 3/1/21 at 1:15 PM. The record contained the SOC comprehensive assessment completed by the RN and dated 10/9/20. The assessment included documentation the Pt. had 3 wounds (#1. Sacral, Stage IV, length 3.3 cm, width 3.1 cm, depth 1.7 cm; #2. Left posterior leg, Stage II, length 4.1 cm, width 0.2 cm, depth 0 cm; #3. Right posterior leg, Stage I, length 3.3 cm, width 0.1 cm, depth 0 cm). The RN visit notes dated 10/15/20 and 10/18/20 contained documentation the Pt. had developed 3 additional wounds (right sacrum, Stage II, length 5.0 cm, width 1.5 cm; left sacrum 5.0 cm, width 2.0 cm; and right shin unstageable). The last SN/RN visit was conducted on 11/22/20 which contained: "...Wound to right lower leg closed with black and hard skin..." The Discharge comprehensive assessment form completed by the RN and dated 11/24/20 included: "Wound to right posterior leg closed with eschar." As of 3/1/21, the record lacked documentation the RN notified the Physician of the new wounds identified on 10/15/20 and 10/18/20, and that the right posterior wound had changed significantly from a Stage I wound to unstageable covered with eschar. 2. Pt. #3. SOC 3/6/20. Primary Diagnosis: Subsequent Encounter Burn of Third Degree of Left Thigh. The clinical record was reviewed on 3/1/20 at 12:30 PM. The record contained the SOC comprehensive assessment dated 3/6/20 which included the Pt. had one wound to the left thigh. The SN visit note dated 3/9/20 included the Pt. developed a "red area at coccyx" measured 0.1 by 0.2 cm. The SN visit notes dated 3/16/20, 3/21/20, 3/28/20, 4/4/20 and 4/11/20 contained documentation the Pt. had developed a "sacral/sacrum" wound. The SN visit note dated 4/11/20 included a measurement of 1.5 length and 2 cm width of the sacral wound. As of 3/1/21, the record lacked documentation the SN notified the Physician regarding the new sacral/sacrum wound prior to the Agency's discharge on 4/18/20. 3. The Agency policy titled, "Care Collaboration Among Interdisciplinary Team" was reviewed on 3/1/21 at 2:40 PM. The policy required, "...2. The agency nurse will communicate to the client's physician pertinent information regarding the client's condition including changes fawned the patient's response to care, treatment and services on a timely basis/manner." 4. During an interview with the DON on 3/1/21 at 1:55 PM and 3/4/21 at 10:36 AM, the DON confirmed the Agency failed to notify the Physician regarding changes in the patient's condition that may warrant a change in the POC.

Discharge plans communication CFR(s): 484.60(c)(3)(ii) (ii) Any revisions related to plans for the patient's discharge must be communicated to the patient, representative, caregiver, all physicians or allowed practitioner's issuing orders for the HHA plan of care, and the patient's 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). This ELEMENT is not met as evidenced by: . A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure discharge plans were communicated to the Pt./family and the Physician, prior to the Agency's discharge. This was found in 2 of 3 (Pts. #1 and 3) closed clinical records reviewed. Findings include: 1. Pt. #1. SOC 10/9/20. Diagnoses: Unspecified Severe Protein-Calorie Malnutrition, Unspecified Stage Pressure Ulcer of Sacral Region and Unspecified Stage Pressure Ulcer of Other Site. The clinical record was reviewed on 3/1/21 at 1:15 PM. The record contained the POC for the certification period of 10/9/20 to 12/7/20. The POC included the section titled "Discharge Plan" this section had "...Discharge when... wound(s) are healed." The Pt. was discharged on 11/24/20 with multiple wounds. The SN visit note dated 11/22/20 included: "...Wound to right lower leg closed with black and hard skin covered with dry gauze." The Agency's discharge comprehensive assessment form completed on 11/24/20 contained a section titled, "Care Coordination" to include the name, title and reason for care coordination, this section was left blank. The same form included a section titled, "Discharge Notices... Physician in agreement with plan to discharge for stated reason", this section was left blank. As of 3/1/21, the record lacked documentation regarding the status of the wound(s) at discharge, discharge planning with the Physician; and/or sharing the discharge needs, continuing care and/or treatment for Pt. #2 with the Pt./family prior to discharge on 11/24/20. 2. Pt. #3. SOC 3/6/20. Primary Diagnosis: Subsequent Encounter Burn of Third Degree of Left Thigh. The clinical record was reviewed on 3/1/20 at 12:30 PM. The record contained the SN visit note dated 4/11/20 which contained documentation the Pt. had "Sacral... Pressure Ulcer Stage II". The Pt. was discharged from the Agency on 4/18/20. During an interview with the DON on 3/4/21 at 10:36 AM, the DON stated when the Pt. was discharged from the Agency on 4/18/20, the Pt. still had the wound. The record and/or Discharge comprehensive assessment completed by the RN and dated 4/18/20 lacked documentation indicating the Pt. had a wound, discharge planning with the Physician (prior to 4/18/20); and/or sharing the discharge needs, continuing care and/or treatment for Pt. #3 with the Pt./family, prior to the Agency discharge on 4/18/20. 3. The Agency policy titled, "Information and Education on Discharges or Transfers" was reviewed on 3/1/21 at 2:30 PM. The policy required: "...2. The agency nurse will inform the patient of the kinds of continuing care, treatment, or services he or she will need before the patient is discharged from the agency. 3. Before the patient is discharged or transferred, the agency nurse will provide the patient with information about why he or she is being discharged or transferred..." 4. During an interview with the DON on 3/1/21 at 1:55 PM and 3/4/21 at 10:36 AM, the DON confirmed the Agency failed to ensure discharge plans were communicated to the Pts./family and the patient's Physicians indicated above.

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: . A. Based on in-service meeting minutes, Agency policy and staff interview, it was determined the Agency failed to ensure the performance improvement project was implemented. This has the potential to affect all services provided by the Agency. Findings include: 1. The form titled, "Plan Of Action For Quality Improvement Team Members" with the "Outcome Report Date: 3/3/2020, Plan of Action: 3/18/2020." The form identified the problem as "Spread of coronavirus." The "Target Outcome Addressed by Plan Of Action: Improvement in infection control measures such as handwashing and donning and doffing of PPE." The project required, "Review with the employees about infection control and do return demo in handwashing and donning and doffing of PPE." The form does not include the members of the Quality Improvement Team, and documentation to show that the project was implemented in 2020 and/or 2021. 2. The "In-Service Meeting" minutes dated 2/24/19 contained multiple topics including: "Review of Use of PPE when caring for patients with confirmed or suspected COVID-19." The "In-Service Meeting" minutes dated 4/15/20 to 4/17/20 contained multiple topics including: "COVID-19 Workplace health and safety guidance for employee and staff of business... Interim guidance for healthcare facilities preparing for community transmission of COVID-19 in the US." The "In-Service Meeting" minutes dated 6/8/20 to 6/9/20 contained multiple topics including: "Handwashing and Sequence of donning and doffing." Each In-Service Meeting Minutes lacked the names of the employees that received the in-services and the individual responsible for conducting the in-services. No other documentation to show who attended was presented by the Agency. 3. The Agency policy titled, "Quality Assurance Performance Improvement Program" was reviewed on 3/10/21 at 11:16 AM. The policy required: "...4. The agency will take actions aimed at performance improvement and, after implementing those actions, will measure its success and tract performance to ensure that improvements are sustained." 4. During an interview with the Director of Nursing on 3/11/21 at 10:20 AM, the Director of Nursing stated: "They (Quality Assessment and Performance committee members) met 2 times in 2020, I do not recall the dates." The Director of Nursing was unable to provide any meeting minutes for 2020, and stated there were no meetings conducted in 2021. The Director of Nursing stated in 2020 there were 2 members on the quality committee which consisted of the Director of Nursing and another RN. 5. During an interview with the Director of Nursing on 3/10/21 at 9:20 AM and 3/11/20 at 10:30 AM. The Director of Nursing confirmed the Agency failed to implement its performance improvement project.

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: . A. Based on review of clinical records and staff interview, it was determined that the Agency failed to ensure staff screened Pts. for COVID-19, prior to providing Pt. care and services. This was found in 5 of 5 (Pts. #4, 5, 6, 7 and 8) active clinical records reviewed. Findings include: 1. Pt. #4. SOC 2/16/21. Primary Diagnosis: Permanent Atrial Fibrillation. The clinical record was reviewed on 3/10/21 at 10:00 AM. The record contained documentation the SN provided service 1 to 2 times a week from 1/12/21 to 3/2/21, the Physical Therapist provided service 1 to 2 times a week from 2/18/21 to 3/8/21, and the Occupational Therapist provided service weekly from 2/18/21 to 3/8/21. The SN, Physical Therapy and Occupational Therapy visit notes/assessments lacked documentation the staff screened the Pt./cg. for COVID-19 symptoms, prior to providing service, as required by the Agency. 2 . Pt. #5. SOC on 1/8/21. Primary Diagnosis: Hypertensive heart disease without heart failure. The record was reviewed on 3/9/21 at 11:00 AM. The record included SN visit notes for 1 to 2 times a week from 1/9/21 to 3/5/21, indicating the SN provided service. The SN visit notes lacked documentation the SN screened the Pt./cg. for COVID-19 symptoms, prior to providing service, as required by the Agency. 3 . Pt. #6. SOC on 3/3/21. Primary Diagnosis: Essential hypertension. The record was reviewed on 3/9/21 at 12:00 PM. The record did not include any SN visit notes for 1 to 2 times a week from 3/3/21 to 3/9/21, indicating the SN provided service or screened the Pt./cg. for COVID-19 symptoms, prior to providing service, as required by the Agency. 4 . Pt. #7. SOC Primary Diagnosis: Essential (Primary) Hypertension. The clinical record was reviewed on 3/10/20 at 9:40 AM. The record contained documentation the SN provided service 1 to 2 times a week from 1/12/21 to 2/2/21. The SN visit notes lacked documentation the SN screened the Pt./cg. for COVID-19 symptoms, prior to providing service, as required by the Agency. 5 . Pt. #8. SOC 01/23/20. Diagnoses: Site Not Specified Urinary Tract Infection and Stage 3 Pressure Ulcer of Right Buttock. The clinical record was reviewed on 3/9/21 at 4:00 PM. The record contained documentation the SN provided service 1 to 2 times a week from 1/14/21 to 2/24/21. The SN visit notes lacked documentation the SN screened the Pt./cg. for COVID-19 symptoms, prior to providing service, as required by the Agency. 6. During an interview with the Director of Nursing on 3/10/21 at 9:20 AM, the Director of Nursing stated: "the staff call the Pt. the day of the visit and ask if they or their family have any (COVID-19) symptoms, or don't feel good... It should be documented in the clinical record... I'm not sure how we are going to do it..." 7. During an interview with the Director of Nursing on 3/10/21 from 1:30 PM to 4:00 PM, the Director of Nursing confirmed the Agency lacked any documentation indicating staff screened Pts./caregivers for COVID-19, prior to providing Pt. care, as required by the Agency, as well as not having any knowledge regarding COVID19 screening procedures and guidelines.

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: . A. Based on review of the Agency's patient admission packet, review In-service Meeting minutes, interview during a home visit and staff interview, it was determined the Agency failed to ensure staff and Pts. receive infection control and prevention education relative to COVID-19. This has the potential to impact all Pts. and staff within the Agency. Findings include: 1. The patient's admission packet was reviewed on 3/9/21 at 9:40 AM and lacked information for Pts./caregiver regarding the prevention and transmission of COVID-19. 2. The In-service meeting minutes 2/24/19, 6/8/20 to 6/9/20 and 4/15/20 to 4/17/20 contained topics pertaining to the prevention and transmission of COVID-19. The meeting minutes lacked the names of the employees that received the in-services and the individual responsible for conducting the in-services. 3. A home visit was conducted on 3/9/21 at 12:20 PM. During the home visit an interview was conducted with the caregiver that stated, "I haven't received anything from the Agency written about COVID, I have seen information on the TV." 4. During an interview with the Director of Nursing on 3/10/21 at 9:20 AM, the Director of Nursing stated: "We instruct them (the Pts.) about COVID verbally, and about getting the shot. I don't give them anything, but I know I should." During the same interview on 3/10/21, the Director of Nursing confirmed the above findings.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: . A. Based on a review of the Agency's organizational chart and staff interview, it was determined the organizational chart was inaccurate. This has the potential to affect all services provided by the Agency. Findings include: 1. The undated organizational chart was reviewed on 3/10/20 at 9:50 AM. The chart did not include the titles and line of supervision . The chart also identified the Pt. reporting to "All Contracted & Independent Services" and "Billing Services." 2. During an interview with the Director of Nursing on 3/10/21 at 9:55 AM, The Director of Nursing stated: "The organization chart is wrong, the Pt. reports to the field nurse, the field nurse reports to the Agency Supervisor, the Agency Supervisor reports to the Administrator." During the same interview, the Director of Nursing confirmed the organizational chart was inaccurate.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure the clinical record contained a description of treatment provided to the Pt. This was found in 1 of 3 (Pt. #1) clinical records reviewed, wherein the Pt. required wound care. Findings include: 1. Pt. #1. SOC 10/9/20. Diagnoses: Unspecified Severe Protein-Calorie Malnutrition, Unspecified Stage Pressure Ulcer of Sacral Region and Unspecified Stage Pressure Ulcer of Other Site. The clinical record was reviewed on 3/1/21 at 1:15 PM. The record contained the SOC comprehensive assessment form completed by the RN. The assessment form included a section titled "Wound Care Flowsheet" which included a description of 3 wounds (sacral, left and right posterior legs), and documentation that "wound care... completed". The assessment lacked a description of the wound care/treatment provided. 2. The Agency policy titled, "Complete and Accurate Patient Records" was reviewed on 3/1/21 at 2:00 PM. The policy required: "...Procedure 1. The individual patients medical records shall contain patient-specific information appropriate to the individual patient's care as... j... therapeutic procedures... relevant to the management of the patient's condition..." 3. During an interview with the Director of Nursing on 3/4/21 at 10:36 AM, the DON confirmed the SOC assessment lacked a description of the wound care/treatment provided to Pt. #1.

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: . A. Based on a review of clinical records, Agency policy and staff interview, it was determined the Agency failed to complete a discharge summary and/or forward a copy of the discharge summary to the Physician, per Agency policy. This was found in 3 of 3 (Pts. #1, 2 and 3) closed clinical records reviewed. Findings include: 1. Pt. #1. SOC 10/9/20. Diagnoses: Unspecified Severe Protein-Calorie Malnutrition, Unspecified Stage Pressure Ulcer of Sacral Region and Unspecified Stage Pressure Ulcer of Other Site. The clinical record was reviewed on 3/1/21 at 1:15 PM. Pt. #1 was discharged on 11/22/20. The record contained the form titled, "Discharge Summary" completed by the RN on 1/23/21. The record lacked documentation that a copy of the summary was sent to the Physician, and that the summary was completed in the time frame, as required by the Agency. 2. Pt. #2. SOC 4/6/20. Diagnoses: Unspecified Atrial Fibrillation and Multiple Sites Muscle Wasting and Atrophy. The clinical record was reviewed on 3/1/21 at 11:30 AM. Pt. #2 was discharged on 4/24/20. The record contained the SOC comprehensive assessment dated 4/6/20, SN visit notes 4/17/20 and 4/14/20, and the Discharge comprehensive assessment completed by the RN and dated 5/26/20. As of 3/1/21, The record lacked documentation that a copy of the summary was sent to the Physician, and that the summary was completed in the time frame, required by the Agency. 3. Pt. #3. SOC 3/6/20. Primary Diagnosis: Subsequent Encounter Burn of Third Degree of Left Thigh. The clinical record was reviewed on 3/1/20 at 12:30 PM. Pt. #3 was discharged on 4/18/20. The record contained the SN visit note dated 4/11/20, indicating that was the last day the SN provided service. The "Discharge Summary" was completed by the RN on 5/12/20. The record lacked documentation that a copy of the summary was sent to the Physician, and the summary was completed in the time frame, required by the Agency. 4. The Agency's policy titled, "Discharge Process" was reviewed on 3/1/21 at 2:20 PM. The policy required: "...8. A discharge summary will be completed for all discharged patients. A copy will be mailed to the primary physician. 9. All discharge paperwork will be due in the office within 72 hours of the discharge dated. This will include the... discharge summary..." 5. During an interview with the DON on 3/1/21 at 1:55 PM and 3/4/21 at 10:36 AM, the DON confirmed the Agency failed to ensure a discharge summary was completed and/or a copy was forwarded to the Physician in a timely manner..

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: . A. Based on review of clinical records, Agency policy and staff interview, it was determined the Agency failed to ensure that clinical documentation entered into the clinical record was completed and accurate. This was found in 3 of 3 (Pts. #1, 2 and 3) closed clinical records reviewed. Findings include: 1. Pt. #1. SOC 10/9/20. Diagnoses: Unspecified Severe Protein-Calorie Malnutrition, Unspecified Stage Pressure Ulcer of Sacral Region and Unspecified Stage Pressure Ulcer of Other Site. The clinical record was reviewed on 3/1/21 at 1:15 PM. The record contained the SN visit notes dated 10/10/20 and 10/12/20 which included documentation the SN/RN provided wound care to the patient's wounds (sacral, left and right posterior legs). A description of the wound care consisted of cleaning the wounds with normal saline, applied "Calcium Alginate" over the wounds, cover with a gauze dressing and secured with tape. The same SN visit notes included the RN cleaned the same wounds with normal saline, applied "wet to dry dressing" and covered wounds with gauze. The RN visit notes contained conflicting documentation as to which treatment/wound care was provided on 10/10/20 and 10/12/20. The form titled, "Authorization and Agreements For the Home Health Services" was signed by the Pt. The form lacked the date it was completed, the "Witness" (RN) name/signature, as required by the Agency's form. The form titled "Patient Rights and Responsibilities" signed by the Pt. and dated 10/9/20 lacked the name/signature of the "Witness". 2. Pt. #2. SOC 4/6/20. Diagnoses: Unspecified Atrial Fibrillation and Multiple Sites Muscle Wasting and Atrophy. The clinical record was reviewed on 3/1/21 at 11:30 AM. The record contained the SN visit note dated 4/24/20 which lacked the SN's name/signature and the date the note was entered into the clinical record. 3. Pt. #3. SOC 3/6/20. Primary Diagnosis: Subsequent Encounter Burn of Third Degree of Left Thigh. The clinical record was reviewed on 3/1/20 at 12:30 PM. The record contained the SOC comprehensive assessment dated 3/6/20 which included the Pt. had one wound to the left thigh. The SN visit note dated 3/9/20 included the Pt. developed a "red area at coccyx." The SN visit notes dated 3/16/20, 3/21/20, 3/28/20, 4/4/20 and 4/11/20 contained documentation the Pt. had developed a "sacral/sacrum" wound. The Discharge comprehensive assessment completed by the RN and dated 4/18/20 contained: "Patient has no pressure ulcer/injuries or no stageable pressure ulcers/injuries." During an interview with the DON on 3/4/21 at 10:36 AM, the DON stated "Yes, the Pt. had a wound when the Pt. was discharged from the Agency." The record contained conflicting documentation, indicating whether the Pt. had a wound at discharge. 4. The Agency policy titled, "Complete and Accurate Patient Records" was reviewed on 3/1/21 at 2:00 PM. The policy required: "...will maintain an accurate, complete medical record for all patients who are assessed, cared for..." 5. During an interview with the DON on 3/4/21 at 10:36 AM, the DON confirmed the Agency failed to ensure clinical documentation entered into the clinical record was completed and accurate.