Every finding on record at Grandcare Home Health LLC

A relicensure/recertification entrance conference was conducted on 08/11/2022. The census was: LCHHS: 0 LHH: 0 PAS: 0 Abbreviations: AM - Ante meridiem COVID-19 -Novel Coronavirus Disease of 2019 LCHHS - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services PAS- Personal Assistance Services PM - Post meridiem

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), §485.625(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, 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 record review and interview, the agency failed to review the emergency preparedness plan after each actual emergency response to evaluate its effectiveness and to update the plan as needed for two of two years reviewed (2020 and 2021) in that: The plan was not evaluated and updated following the COVID-19 pandemic that began on 03/14/2020 and the winter storm that occurred on 02/13/2021 through 02/17/2021. This failure placed the agency patients at risk of harm in the event of an emergency or disaster if the agency's emergency plan was not effective. Findings Include: Review of the emergency preparedness documents emailed to the surveyor by the Owner and Administrator on 08/11/2022 revealed no evidence of any records to establish the agency conducted an internal review after the COVID-19 pandemic that began on 03/14/2020 and the winter storm that occurred from 2/13/2021 through 02/17/2021. During an interview with the Administrator and Alternate Administrator on 08/16/2022 at 11:40 AM, the surveyor presented the above findings of why the agency failed to review the emergency preparedness plan after each actual emergency response to evaluate its effectiveness and to update the plan as needed following the COVID-19 pandemic that began on 03/14/2020 and the winter storm that occurred on 02/13/2021 through 02/17/2021. The Alternate Administrator stated that was something the prior employees did not do. During an interview with Alternate Administrator on 08/16/2022 at 1:40 PM, the surveyor presented the above findings of how this failure could have impacted the patients. The Alternate Administrator stated it could have affected patient safety since the agency should have called the patients and asked if they were safe, had power or needed any help. Agency policy titled, “EMERGENCY PREPAREDNESS AND RESPONSE PLAN EC.8” with a revision date of 07/01/2020 read in part, “…PURPOSE… To ensure the Agency develops, establishes, maintains, and implements emergency preparedness policies and procedures…that will be reviewed and updated at least annually…POLICY… The plan and related policies and procedures must be reviewed and updated at least annually…PROCEDURE…VII. Recovery…The Agency will complete an internal review of the plan, policies, and procedures at least annually, and after each actual emergency response, to evaluate its effectiveness and to update the plan as needed…”

A relicensure/recertification entrance conference was conducted on 08/11/2022. The census was: LCHHS: 0 LHH: 0 PAS: 0 Abbreviations: AM - Ante meridiem cg - Caregiver CMS - Centers for Medicare and Medicaid Services DC - Discharge LCHHS - Licensed and Certified Home Health Services LHHS - Licensed Home Health Services No. - Number NOMNC – Notice of Medicare Non-Coverage OASIS- Outcome and Assessment Information Set PAS- Personal Assistance Services PM - Post meridiem Pt – Patient Cg - Caregiver QIO – Quality Improvement Organization SN - skilled nurse RN – Registered Nurse DC - Discharge

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: THIS IS A CONTINUING VIOLATION FROM SURVEY DATED 08/07/2019 CITED AT G0442. Based on record review and interview, the agency failed to provide a completed written Notice of Medicare Non-Coverage (FORM No. CMS 10123) no later than two days in advance of terminating on-going care whose reason for discharge was goals met in three of three (Patient 1, 2 and 3) discharged patient records reviewed. The agency failed to provide the CMS form titled, “Notice of Medicare Non-Coverage". The failure could place the patients at risk of harm due to inadequate or inappropriate continuity of care in the patients' post-discharge needs and could prevent the patients from exercising the right to appeal the discharge decision, if desired. Findings Include: Patient 1: Record review of the electronic record included a plan of care dated 01/28/2021 to 03/28/2021 with a start of care date of 09/30/2020. The record contained a SN discharge OASIS signed and dated by Prior Director of Nurses on 03/27/2021. The discharge OASIS included a discharge summary that read in part, “…Reason for discharge: Goals met…Instructed pt/cg that she will be discharged from home health services effective today…condition stabilized and goals are met…” The record did not include a Notice of Medicare Non-Coverage FORM No. CMS 10123. Patient 2: Record review of the electronic record included a plan of care dated 06/16/2021 to 08/14/2021 with a start of care date of 04/17/2021. The record contained a SN discharge OASIS signed and dated by Prior Director of Nurses on 08/13/2021. The discharge OASIS included a discharge summary that read in part, “…Reason for discharge: Goals met…Instructed pt/cg that she will be discharged from home health services effective today…condition stabilized and goals are met…” The record did not include a Notice of Medicare Non-Coverage FORM No. CMS 10123. Patient 3: Record review of the electronic record included a plan of care dated 10/11/2020 to 12/09/2020 with a start of care date of 09/08/2015. The record contained a SN discharge OASIS signed and dated by RN on 12/09/2020. The discharge OASIS included a discharge summary that read in part, “…Reason for discharge: Goals met…Patient was discharged from home health services due to goals met…” The record did not include a Notice of Medicare Non-Coverage FORM No. CMS 10123. During a telephone interview with the Director of Nurses on 08/16/2022 at 12:55 PM, the surveyor presented the above findings of why the agency failed to provide a completed written Notice of Medicare Non Coverage (FORM No. CMS 10123) no later than two days in advance of terminating on-going care whose reason for discharge was goals met for Patient 1, 2 and 3. The Director of Nurses stated she did not know because that happened before she worked for the agency. The surveyor presented the above findings of the potential impact to Patient 1, 2 and 3 of not receiving a completed written Notice of Medicare Non Coverage (FORM No. CMS 10123) no later than two days in advance of terminating on-going care. The Director of Nurses stated it could have greatly impacted the patient’s future care as they might have needed to talk to their provider in advance of discharge about future blood draws and treatments. Agency policy titled, "PATIENT/CLIENT TRANSFER AND DC NOTICES PE.6" with a revision date of 08/01/2020 read in part, " ... PURPOSE To provide guidance on completion of the required ...discharge notices... POLICY I. Prior to ...discharging a patient/client, the Agency will provide written notification to the patient/client or the patient's/client's parent, family, spouse, significant other or legal representative…III. The Agency will deliver the Notice of Medicare Non-Coverage ...to the patient/client (or authorized representative), at least two (2) calendar days before Medicare covered services end ...C. The Agency will keep the following in the patient's/client's file: 1. A copy of the written notification provided to the patient/client or their parent, family, spouse, significant other, or legal representative ... II. Notice of Medicare Non-Coverage (NOMNC) ... A. Agency staff will provide valid delivery notice (involves both delivery and completion) of the NOMNC to the patient/client (or their representative) when the end of all covered care is foreseen, even if the patient/client agrees with the discharge. B. At least two (2) calendar days before Medicare covered services end...the Agency representative will provide the NOMNC to the patient/client ... I. The Agency will have the patient/client (or their representative) complete and sign the NOMNC. The patient/client or representative should sign and date two copies, keep one, and return a copy to the Agency ..." Regulation: July 1, 2005, the new Medicare regulations, Benefits Improvement and Protection Act gave beneficiaries access to the new expedited determination process when their home health agency services were ending. There were two notices required by these regulations. The first was a generic notice called a Notice of Medicare Provider Non-coverage labeled "FORM No. CMS 10123" that the provider would be delivered at least two days prior to when a beneficiary's Medicare coverage of services was ending. The telephone number for the QIO was to be included in the notice. The second was a detailed notice, called a Detailed Explanation of Provider Non-Coverage that the provider would deliver to the beneficiary and the appropriate QIO only if the beneficiary requested an expedited review by the QIO of the decision that coverage for items and/or services should end.