Every finding on record at Greater Cleveland Home Health Care, Inc

EMERGENCY PREPAREDNESS SURVEY At the time time of the emergency preparedness survey completed on 03/09/21, Greater Cleveland Home Health Care, Inc is in compliance with the provision at 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

PARTIAL EXTENDED RECERTIFICATION SURVEY SUBSTANTIAL ALLEGATION SURVEY SUBSTANTIAL ALLEGATION OH000120313 COVID 19 FOCUSED INFECTION CONTROL SURVEY An entrance conference was conducted on 03/01/21 with the Administrator. An exit conference was conducted on 03/09/21 with administrative staff. The following deficiencies are based on the COVID 19 Focused Infection Control Survey and the Partial Extended Recertification Survey completed on 03/09/21. Greater Cleveland Home Health Care 368378, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies. No deficiencies were issued in regard to allegations contained in Substantial Allegation OH00120313 investigated concurrently.

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: Based on medical record review, staff interview, and policy review, the agency failed to ensure plan of care included the frequency of visits to be made for ten of ten patients reviewed with home health aides services (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10) The census was 81. Findings include: The agency policy titled, Plan of Care - CMS #485 and Physician Orders (Revised October 2017) was reviewed and revealed "the individulaized plan of care must include" among other things "the frequency and duration of visits to be made." 1. Review of Patient #1's plan of care for the period dated 02/19/21-04/19/21 lacked a frequency for home health aide visits, specifying only 30.5 hours per week. 2. Review of Patient #2's plan of care for the period dated 02/06/21-04/06/21 lacked a frequency for home health aide visits, specifying only 25-30 hours per week. 3. Review of Patient #4's plan of care for the period dated 11/25/2020-01/23/21 lacked a frequency for home health aide visits, specifying only 27 hours per week. Staff A was made aware of and confirmed the above findings on 03/04/21 at 1:57 PM. 4. Review of Patient #3's plan of care for the period dated 12/29/2020-02/26/21 lacked a frequency for home health aide visits, specifying only 18-27 hours per week. 5. Review of Patient #5's plan of care for the period dated 02/22/21-04/22/21 lacked a frequency for home health aide visits, specifying only 14-28 hours per week. 6. Review of Patient #6's plan of care for the period dated 08/09/19-10/07/19 lacked a frequency for home health aide visits, specifying only 56 hours per week. 7. Review of Patient #7's plan of care for the period dated 05/29/20-07/27/20 lacked a frequency for home health aide visits, specifying only 24 hours per week. 8. Review of Patient #8's plan of care for the period dated 01/29/21-03/29/21 lacked a frequency for home health aide visits, specifying only 14 hours per week. 9. Review of Patient #9's plan of care for the period dated 01/26/21-03/26/21 lacked a frequency for home health aide visits, specifying only 10-14 hours per week. 10. Review of Patient #10's plan of care for the period dated 02/04/21-04/04/21 lacked a frequency for home health aide visits, specifying only 14 hours per week. Per interview on 03/09/21 at 5:30 PM Staff J was made aware of these findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and staff interview, the agency failed to maintain a coordinated agency wide program for the identification, prevention and control of COVID-19 for ten of ten patients reviewed with home health aide services (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10). The census was 81. Findings include: Review of the undated agency policy titled, "Pandemic Infectious Disease," revealed the staff will ask the patients if they traveled internationaly within the last 14 days, does the patient have any signs or symptoms of a respiratory infection, fever, cough or sore throat, and within the last four days have they been in contact with someone with COVID or a respiratory illness. Home Health Aides are to complete a screening on the back of their time sheet. They are to complete one area for the patient and one area for themselves. Review of the patient records for Patient #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10 revealed they all received home health aide services. There was no evidence on the back of the home health aide times sheets that the home health aides screened the patients for possible COVID-19 prior to visit, per policy. Per interview on 03/09/21 at 1:49 PM Staff J confirmed the home health aides were supposed to be screening the patients on the back of the visit sheet prior to each visit and confirmed that it had not been done.