Every finding on record at Healthcare Stat Home Care, Inc.

Based on the findings of an onsite unannounced Medicare recertification survey conducted June 27, 2023, through June 29, 2023, Healthcare Stat Homecare, Inc., was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

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 interview with the administrator/director of nursing, review of agency documentation and the agency's emergency preparedness plan, the agency failed to base the emergency preparedness plan on and to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Based on interview with the administrator/director of nursing, review of agency documentation and the agency's emergency preparedness plan, the agency failed to base the emergency preparedness plan on and to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings include: A review of the agency emergency preparedness plan was conducted on June 29, 2023 at approximately 2:00 P.M. There was no documentation that the emergency preparedness plan was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Interview with the administrator/director of nursing on June 29, 2023 at approximately 2:30 P.M. confirmed the above findings.

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 a review of facility policies/procedures, documentation, and interview with the administrator and director of nursing, the facility failed to ensure the emergency preparedness plan included the contact information for agency staff. Findings include: Review of the agency's Emergency Preparedness Plan on 6/29/23 at approximately 12:00 PM. revealed no contact information for the agency staff. During interview on 6/29/23 at approximately 2:30 P.M., the administrator and director of nursing confirmed the above finding.

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 Emergency Preparedness documents provided by the agency, and an interview with the administrator and director of nursing, the agency failed to provide evidence that the emergency preparedness plan was tested annually. Findings Include: A review of the home health agency's emergency preparedness documents on 6/29/23 at approximately 12:00 PM did not contain any evidence that exercises to test the emergency preparedness plan were conducted annually. An interview conducted with the administrator and director of nursing on 6/29/23 at approximately 2:30 pm confirmed the above findings.

Based on the findings of an onsite unannounced Medicare recertification survey conducted June 27, 2023, through June 29, 2023, Healthcare Stat Homecare, Inc., was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on review of iQies reports, agency policy, clinical records (CR) and interview with the administrator and director of nursing, the agency failed to follow its policy regarding transmitting OASIS (outcome and assessment information set) for three (3) of seven (7) clinical records reviewed. (CR # 1, 2 & 7). Findings included: Review of iQies reports on 6/26/23, at 11:00 A.M. revealed that the agency had not transmitted any OASIS information since 6/3/22. An interview was conducted with the administrator and the director of nursing on 6/28/23, at approximately 11:00 A.M. When asked if the agency collects and transmits OASIS data, the administrator and the director of nursing stated that they have not in a while. Review of clinical records on 6/27/23 and 6/28/23 at approximately 10:00 AM. revealed the following: CR #1, start of care 6/19/15, contained physician orders for skilled nursing (SN) 96 hours per week. The CR contained no evidence of the transmission of OASIS data at the time of recertification since 6/3/22. CR #2, start of care 11/5/21, contained physician orders for SN thirteen (13) hours per day, seven (7) days a week. The CR contained no evidence of the transmission of OASIS data at the time of recertification since 6/3/22. CR#7, start of care 9/8/14 contained physician orders for SN twenty-four (24) hours daily (shared with another agency). The CR contained no evidence of the transmission of OASIS data at the time of recertification since 6/3/22. Interview with the administrator and director of nursing on 6/29/23, at approximately 2:30 P.M. confirmed that the agency has not been transmitting OASIS data since 6/3/22 for any eligible patients.

Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient's condition warrants due to a major decline or improvement in the patient's health status, but not less frequently than- This STANDARD is not met as evidenced by: Based on clinical record review, review of policy, and an interview with the director of nursing and administrator, the registered Nurse did not complete a recertification assessment for one (1) of seven (7) clinical records reviewed (CR #6). Findings include: A review of agency policy on 6/29/23 at approximately 12:00PM revealed the following: Policy titled, "Plan of Care" stated, "The plan of care will be reviewed at least every 60 days, based upon a professional reassessment of the patient and at any time the patient's change of condition warrants revision. At the review, the plan of care is written to reflect changes or current treatment with the date and nurse's signature. Review/assessment should be performed within 5 days prior to expiration of the 485 (plan of care)." Policy titled, "RN Performing OASIS SOC (Start of Care), Resumptions (ROC) and Recertifications" stated, "This needs to be comprehensive assessment, all body systems need to be addressed and documented, all wounds must be measured, document the wound bed, surrounding area, drainage, and perform wound care on the same day of SOC, ROC and recerts, all sections of the wound care sections need to be performed...all the OASIS (Outcome and Assessment Information Set) needs to be documented..." Review of Clinical record occurred on 6/27/23 and 6/28/23 at approximately 9:30 AM and revealed the following: CR#6. Start of Care: 3/13/23. Certification period reviewed: 5/12/23-7/10/23. There was no documentation of a registered nurse recertification assessment completed for this certification period. An interview with the agency's administrator and director of nursing on 6/29/23 at approximately 2:30 PM confirmed the above findings.

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 upon clinical record review, and an interview with the Director of Nursing and Administrator, it was determined the agency failed to ensure length of service provided was listed on the Plan of Care for seven (7) of seven (7) clinical records reviewed (CR# 1, 2, 3, 4, 5, 6 &; 7). Findings include: Policies were reviewed on 6/29/23 at approximately 12:00 PM and revealed the following: Policy titled "Plan of Care" states, "The Plan of Care (HCFA form 485) will be individualized to the specific patient and will include at least...Frequency and duration of visits..." Clinical records were reviewed on 6/27/23 and 6/28/23 at approximately 9:30 AM and revealed the following: CR#1. Start of Care: 6/19/15. Certification period reviewed: 5/8/23-7/6/23 Skilled Nursing ordered for 96 hours weekly. There was no listed duration on the plan of care. CR#2. Start of Care: 11/5/21. Certification period reviewed: 4/29/23-6/27/23. Skilled Nursing ordered for thirteen (13) hours per day for seven (7) days a week. There was no listed duration on the plan of care. CR#3. Start of Care: 2/20/23.Certification period reviewed:6/20/23-8/18/23. Skilled Nursing ordered for twelve (12) hours per day Monday through Friday. There was no listed duration on the plan of care. CR#4. Start of Care: 3/8/22. Certification period reviewed: 5/2/23-6/30/23. Skilled Nursing ordered for twelve (12) hours per day seven (7) days a week. There was no listed duration on the plan of care. CR #5. Start of Care: 8/5/21. Certification period reviewed: 5/27/23-7/25/23. Skilled Nursing ordered for reassement only every sixty (60) days, and Home Health Aides (HHA) ordered for eight (8) hours per day Monday through Friday. There was no listed duration on the plan of care. CR#6. Start of Care: 3/13/23. Certification period reviewed: 5/12/23-7/10/23. Skilled Nursing ordered for eight (8) hours overnight on Monday through Friday and six (6) hours during the day from 5:00 PM-11:00PM. There was no listed duration on the plan of care. CR#7. Start of Care: 9/8/15. Certification period reviewed: 3/15/23-5/23/23. Skilled Nursing ordered for twenty-four (24) hours per day. There was no listed duration on the plan of care. An interview the Administrator and Director of Nursing on 6/29/23 at approximately 2:30 PM confirmed the above findings.

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: Based on clinical record review, review of agency policy, and an interview with the administrator and director of nursing the agency failed to ensure physician orders were followed for five (5) of seven (7) clinical records reviewed (CR #1, 3, 4, 6 & 7). Findings include: Review of agency policy occurred on 6/28/23 at approximately 12:00 PM and revealed the following: Policy titled, "Plan of Care" states, "The Plan of Care (HCFA form 485) will be developed right after the initial assessment and will be consistent with the comprehensive assessment and physician orders." Policy titled, "Ongoing Assessments" states, "During each home visit, the clinical or other discipline will be re-evaluate the patient according to the problems identified during the initial visit and subsequent visits...using the standard of care identifies by the agency, the clinician will reassess the patient for...blood pressure, pulse, respirations, temperature...breath sounds, skin integrity...The physician will be notified to verify any changes in medication...care and treatment or services that require a physician approval." Policy for wound assessment was requested from the administrator on 6/29/23 at approximately 1:00 PM who stated that the agency does not have one. Policy titled, "RN Performing OASIS SOC (Start of Care), Resumptions (ROC) and Recertifications" stated, "This needs to be comprehensive assessment, all body systems need to be addressed and documented, all wounds must be measured, document the wound bed, surrounding area, drainage, and perform wound care on the same day of SOC, ROC and recerts, all sections of the wound care sections need to be performed...all the OASIS (Outcome and Assessment Information Set) needs to be documented..." A review of the "Organization of Wound Care Nurses & Allied Health professionals" website on 6/29/23 at approximately 2:00PM under "Wound Care management" stated that "It is extremely important to measure the wound periodically since it shows the actual progress of the wound...Weekly wound imaging is the recommended best practice..." Review of Clinical records took place on 6/27/23 and 6/28/23 at approximately 10:00 AM and revealed the following: CR#1. State of Care: 6/19/15. Certification period reviewed: 5/8/23-7/6/23. On the Home Health Certification and Plan of Care (485) it contains an order for skilled nursing 96 hours weekly. In addition, there is an order that states, "Cleanse sacral wound with NSS (normal saline solution) or soap and water, pat dry, apply A&D ointment (a skin protectant), cover with absorbent silicone foam with adhesive border and change every 3 days." In reviewing skilled nursing visits from the above certification period there was no documentation about wound treatment being performed every three (3) days. During the following weeks the agency did not provide skilled nursing for a total of 96 hours. On 5/14/23-5/20/23 82 hours were documented, 5/21/23-5/27/23 84 hours were documented, 5/28/23-6/3/23 83 hours were documented, 6/4/23-6/10/23 84 hours were documented, 6/11/23-6/17/23 82 hours were documented. There was no documentation about physician notification regarding the change in hours provided or any documentation of verbal orders obtained changing the skilled nursing frequency. CR#3. Start of Care:2/20/23. Certification period reviewed: 6/20/23-8/18/23. On the Home Health Certification and Plan of Care contained skilled nursing ordered for twelve (12) hours a day Monday through Friday. On the following dates only eight (8) hours of skilled nursing was provided: 6/20/23, 6/21/23, 6/22/23, 6/23/23 & 6/24/23. There was no documentation about physician notification regarding the change in hours provided or any documentation of verbal orders obtained changing the skilled nursing frequency. CR#4. Start of Care: 3/8/22. Certification period reviewed: 5/2/23-6/30/23. On the Home Health certification and Plan of care it states, "Sacral wound. Assess site twice daily." On the recertification assessment completed on 5/26/23 due to hospitalization it states, "Incision wound on right hip." There is no documentation about the surgical incision or sacral site including measurement, wound status, or what type of closure the incision contains. Hospital discharge paperwork dated 5/25/23 states, "Hospital admission 5/1/23-5/24/23...Keep incision covered until follow-up....keep incision clean, dry and intact. Change dressing QOD (every other day) or if saturated." There was no documentation that this wound treatment recommendation was on the Home Health certification and Plan of care or a verbal order obtained. There was no documentation from subsequent skilled nursing visits after return from hospital about any wound assessment, treatment, or wound status. In additional hospital discharge paperwork dated 5/25/23 also stated, "She does have two stage one pressure areas on the lateral and medial aspect of right ankle from the bucks traction. Both measure about 1.5 cm X 1.5 cm. Areas are red, closed and blanchable" There was no documentation about these areas on the nursing recertification assessment completed on 5/26/23. In addition, in reviewing skilled nursing documentation from visits conducted during the recertification period 5/2/23-6/30/23 there were multiple days of missing or incomplete vital signs obtained. On the following days there was no skilled nursing documentation of any vital signs obtained (including temperature, pulse, respirations, blood pressure, and pulse-oximetry): 6/8/23 and 6/9/23. On the following days there was no documentation of the temperature, respiration, pulse or blood pressure documentation from the skilled nurse: 5/26/23, 6/1/23, 6/2/23, 6/15/23, 6/16/23, 6/22/23, 6/23/23. CR#5. Start of Care: 8/5/21. Certification period reviewed: 5/27/23-7/25/23. The recertification assessment completed on 5/26/23 did not contain documentation of any vital signs (including temperature, pulse, respirations, blood pressure and pulse-oximetry) CR#6. Start of Care: 3/13/23. Certification period reviewed: 5/12/23-7/10/23. The Home Health certification and Plan of Care contained orders for skilled nursing eight (8) hours overnight Monday through Friday and six (6) hours during the day Monday through Friday (for a total of 14 hours daily). On the following dates there was not a total of 14 hours provided by the agency. On 6/12/23, 6/15/23, 6/17/23 there were only 6 hours provided, on 6/16/23 and 6/18/23 there were only 2 hours provided, and on 6/19/23 there were no hours provided. There was no documentation about physician notification regarding the change in hours provided or any documentation of verbal orders obtained changing the skilled nursing frequency. CR#7. Start of Care: 9/8/14. Certification period reviewed: 3/25/23-5/23/23. Patient passed away on 4/30/23. The Home Health certification and Plan of Care contained order for Skilled Nursing 24 hours daily (shared case with another agency) and contained a physician order that stated, "Pulse oximeter every 4 hours with vital signs when patient is sleeping." Agency providing skilled nursing from 10PM-7AM and 7AM-5PM daily (which indicates a total of 19 hours of skilled nursing daily). There was no documentation of pulse oximeter checks every four (4) hours with vital signs when patient was sleeping on the following times when agency was providing skilled nurses overnight (10PM-7AM): 3/25/23, 3/26/23, 3/27/23, 3/28/23, 3/29/23, 3/30/23, 3/31/23, 4/1/23, 4/2/23, 4/3/23, 4/4/23, 4/5/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/10/23, 4/11/23, 4/12/23, 4/13/23, 4/14/23, 4/15/23, 4/16/23, 4/17/23, 4/18/23 and 4/19/23. The Home Health certification and Plan of Care for the above certification period also contained an order that stated, "Endocrine: Glucose check X2 (twice) daily before feeds in the AM and PM." In reviewing the skilled nursing visits for the certification period 3/25/23-5/23/23 there was no documentation of any glucose checks completed. An interview with the agency's administrator and director of nursing on 6/29/23 at approximately 2:30 pm confirmed the above findings.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on clinical record review, review of agency policy, and an interview with the administrator and director of nursing the agency failed to ensure a skilled nurse perform wound management including assessment and treatment for two (2) of seven (7) clinical records reviewed (CR#1 & 4) and the agency failed to ensure a skilled nurse monitored patients through obtaining a complete set of vital signs during daily nursing visits or recertification for two (2) of seven (7) clinical records reviewed (CR# 4 & 5) and the agency failed to ensure pulse-oximetry (pulse-ox) was documented by a skilled nurse for one (1) of seven (7) clinical records reviewed (CR# 7) and agency failed to ensure documentation by a skilled nurse of blood sugar (BS) for one (1) of seven (7) clinical records reviewed (CR#7). Findings include: Review of agency policy occurred on 6/28/23 at approximately 12:00 PM and revealed the following: The agency's policy concerning wound management was requested on 6/29/23 at approximately 12:00 PM and the Director of Nursing and Administrator stated that the agency did not have a policy concerning wound management. A review of the "Organization of Wound Care Nurses &; Allied Health professionals" website on 6/29/23 at approximately 2:00PM under "Wound Care review: Best practice guidelines" stated that "weekly measurements of wounds shall be completed and documented in the medical records..." Policy titled, "Plan of Care" states, "The Plan of Care (HCFA form 485) will be developed right after the initial assessment and will be consistent with the comprehensive assessment and physician orders." Policy titled, "Ongoing Assessments" states, "During each home visit, the clinical or other discipline will be re-evaluate the patient according to the problems identified during the initial visit and subsequent visits...using the standard of care identifies by the agency, the clinician will reassess the patient for...blood pressure, pulse, respirations, temperature...breath sounds, skin integrity...The physician will be notified to verify any changes in medication...care and treatment or services that require a physician approval." Policy titled, "RN Performing OASIS SOC (Start of Care), Resumptions (ROC) and Recertifications" stated, "This needs to be comprehensive assessment, all body systems need to be addressed and documented, all wounds must be measured, document the wound bed, surrounding area, drainage, and perform wound care on the same day of SOC, ROC and recerts, all sections of the wound care sections need to be performed...all the OASIS (Outcome and Assessment Information Set) needs to be documented..." Review of Clinical record took place on 6/27/23 and 6/28/23 at approximately 10:00 AM and revealed the following: CR#1. State of Care: 6/19/15. Certification period reviewed: 5/8/23-7/6/23. On the recertification assessment completed on 5/22/23 there is documentation that states, "Stage 2 on sacrum." The recertification assessment did not document any identifying data about the wound including measurements or wound status. On the Home Health Certification and Plan of Care (485) there is an order that states, "Cleanse sacral wound with NSS (normal saline solution) or soap and water, pat dry, apply A&D ointment (a skin protectant), cover with absorbent silicone foam with adhesive border and change every 3 days." In reviewing skilled nursing visits from the above certification period there was no documentation about wound treatment was being performed every three (3) days and there also were no wound measurements/wound status documented. CR#4. Start of Care: 3/8/22. Certification period reviewed: 5/2/23-6/30/23. On the Home Health certification and Plan of care it states, "Sacral wound. Assess site twice daily." On the recertification assessment completed on 5/26/23 due to hospitalization it states, "Incision wound on right hip." There is no documentation about the surgical incision or sacral site including measurement, wound status, or what type of closure the incision contains. Hospital discharge paperwork dated 5/25/23 states, "Hospital admission 5/1/23-5/24/23...Keep incision covered until follow-up....keep incision clean, dry and intact. Change dressing QOD (every other day) or if saturated." There was no documentation that this wound treatment recommendation was on the Home Health certification and Plan of care or a verbal order obtained. There was no documentation from subsequent skilled nursing visits after return from hospital about any wound assessment, treatment, or wound status. In additional hospital discharge paperwork dated 5/25/23 also stated, "She does have two stage one pressure areas on the lateral and medial aspect of right ankle from the bucks traction. Both measure about 1.5 cm X 1.5 cm. Areas are red, closed and blanchable" There was no documentation about these areas on the nursing recertification assessment completed on 5/26/23. In addition, in reviewing skilled nursing documentation from visits conducted during the recertification period 5/2/23-6/30/23 there were multiple days of missing or incomplete vital signs obtained. On the following days there was no skilled nursing documentation of any vital signs obtained (including temperature, pulse, respirations, blood pressure, and pulse-oximetry): 6/8/23 and 6/9/23. On the following days there was no documentation of the temperature, respiration, pulse or blood pressure documentation from the skilled nurse: 5/26/23, 6/1/23, 6/2/23, 6/15/23, 6/16/23, 6/22/23, 6/23/23. CR#5. Start of Care: 8/5/21. Certification period reviewed: 5/27/23-7/25/23. The recertification assessment completed on 5/26/23 did not contain documentation of any vital signs (including temperature, pulse, respirations, blood pressure and pulse-oximetry) CR#7. Start of Care: 9/8/14. Certification period reviewed: 3/25/23-5/23/23. Patient passed away on 4/30/23. The Home Health certification and Plan of Care contained order for Skilled Nursing 24 hours daily (shared case with another agency) and contained a physician order that stated, "Pulse oximeter every 4 hours with vital signs when patient is sleeping." Agency providing skilled nursing from 10PM-7AM and 7AM-5PM daily. There was no documentation of pulse oximeter checks every four (4) hours with vital signs when patient was sleeping on the following times when agency was providing skilled nurses overnight (10PM-7AM): 3/25/23, 3/26/23, 3/27/23, 3/28/23, 3/29/23, 3/30/23, 3/31/23, 4/1/23, 4/2/23, 4/3/23, 4/4/23, 4/5/23, 4/6/23, 4/7/23, 4/8/23, 4/9/23, 4/10/23, 4/11/23, 4/12/23, 4/13/23, 4/14/23, 4/15/23, 4/16/23, 4/17/23, 4/18/23 and 4/19/23. The Home Health certification and Plan of Care for the above certification period also contained an order that stated, "Endocrine: Glucose check X2 (twice) daily before feeds in the AM and PM." In reviewing the skilled nursing visits for the certification period 3/25/23-5/23/23 there was no documentation of any glucose checks completed. An interview with the agency's administrator and director of nursing on 6/29/23 at approximately 2:30 pm confirmed the above findings.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on a review of personnel files (PFs), review of policies and procedures, and an interview with the Administrator and Director of Nursing, the agency did not maintain current Cardiopulmonary resuscitation (CPR) certification for clinical staff for one (1) of seven (7) (PF # 6) and personnel files did not contain a current signed job description for two (2) of seven (7) personnel files reviewed (PFs # 6 and 7). Findings include: Review of Policies was conducted on June 29, 2023, at approximately 9:40 am. “Policy: Office manager will review and ensure that the documentation is part of the employee chart: Criminal Background Check, PPD, initial hire physical. Copy of photo ID, Social Security card, completed I- 9 form, state license or certification, three forms of professional references, Hepatitis B vaccine, current CPR card, and proof of status immigration if applicable”. A review of the personnel files was conducted June 29, 2023, at approximately 9:05 am to 9:30 am. PF# 6, Date of Hire (DOH): 9/4/2019. File did not contain a copy of a new signed job description as a RN. Personnel started as Licensed Practical Nurse (LPN) upon hire but is now working as a RN. File contained expired CPR certification, expiration date 8/2021. PF #, 7 DOH: 3/29/2011. Personnel file did not contain a copy of a new signed job description indicating Director of Nursing. Personnel started as an RN upon hire, now working as Director of Nursing. Interview with the Administrator on 6/29/23 at approximately 1:00 PM who confirmed the above findings.

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: Based on a review of clinical records (CRs) and an interview with the administrator and director of nursing, agency failed to provide documentation that a discharge summary was sent to the physician within five (5) days of discharge for two (2) of two (2) discharge records reviewed (CR #6 & 7). Findings Include: Agency policy about discharge summary was requested on 6/29/23 at approximately 12:00 PM and administrator and director of nursing were unable to produce. A review of clinical record conducted on 6/27/23 and 6/28/23 at approximately 9:30 A.M. which revealed the following: CR#6, start of care (SOC): 3/13/23. Patient was discharged from the agency on 5/27/23. There was no documentation that the discharge summary was sent to the physician. CR#7, start of care (SOC): 9/8/14. Patient passed away in the hospital on 5/30/23. There was no documentation that the discharge summary was sent to the physician. An interview with the administrator and director of nursing on 6/29/23 at approximately 2:30 P.M. confirmed the above findings.

Administrator CFR(s): 484.115(a) Standard: Administrator, home health agency. (1) For individuals that began employment with the HHA prior to January 13, 2018, a person who: (i) Is a licensed physician; (ii) Is a registered nurse; or (iii) Has training and experience in health service administration and at least 1 year of supervisory administrative experience in home health care or a related health care program. (2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. This STANDARD is not met as evidenced by: Based on an interview with the agency administrator and director of nursing and a review of agency policy, the agency failed to ensure appointment of a qualified, pre-designated person, who is authorized in writing by the agency's Governing Body and who will assume the same responsibilities and obligations as the administrator for one (1) of seven (7) personnel files (PF #2). Findings include: Agency policies reviewed on 6/29/23 at approximately 12:00 PM and stated the following: "Administrator Job Description" States, "Essential Duties & Responsibilities for Position: One (1) year supervisory and management experience including hiring staff, coaching, performance management, daily operations supervision, discipline and counseling." Entrance Interview conducted with the administrator on 6/27/23 at approximately 9:45 AM who stated that PF#2 is the current alternate administrator for the agency. PF #2. Date of Hire: 4/17/23. File contained RN license that was first issued on 4/4/23 and therefore personnel has less than one-year supervisory and nursing experience. File did not contain a signed job description indicating them as an alternate administrator. A review of governing body minutes on 6/28/23 at approximately 12:30 PM did not reveal approval of PF#2 as the alternate administrator. An interview with the agency administrator and director of nursing on 6/29/23 at approximately 2:30 p.m. confirmed the above findings.