Every finding on record at Holistic Home Health, Corp

EMERGENCY PREPAREDNESS SURVEY At the time of the emergency preparedness survey completed on 06/29/22, Holistic Home Health, Corp is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Partial Extended Recertification Survey An entrance conference was conducted on 06/27/22 at 9:00 AM with a registered nurse. An exit conference was conducted on 06/29/22 with administrative staff. The following deficiencies are based on the partial extended recertification survey completed 06/29/22. Holistic Home Health, Corp 368148, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on record review, policy review, observation and patient and staff interviews, the agency failed to ensure a review of all medications the patient is currently using was completed for one of two patients with home visits (Patient #1). The census was 38. Findings include: Review of agency policy titled, "Drug Regimen Review," effective 05/2012, revealed as part of the comprehensive assessment, review of all medications the patient is currently taking in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, and noncompliance with drug therapy. On 06/27/22 at 3:30 PM a home visit was made to Patient #1 with Staff D present. Review of a medication bottle label revealed Vitamin D 2 50,000 units (supplement) once per month. This was filled 05/02/22. Review of the plan of care dated 05/24/22 revealed the Vitamin D 2 was to be taken daily. Review of the Medication Profile last reviewed on 05/19/22 revealed Vitamin D 2 50,000 units taken daily. Per interview on 06/27/22 at 3:50 PM Patient #1 stated the Vitamin D 2 was taken monthly. Review of a medication bottle label revealed Buspirone HCL 10 milligrams (mg) (medication for anxiety) to be taken three times a day for anxiety. This was filled 05/02/22. Review of the plan of care dated 05/24/22 revealed Buspirone HCL was not listed. Review of the Medication Profile revealed Buspirone HCL 10 mg taken twice a day. Review of the Medication List from the physician's office revealed the Buspirone was to be taken three times a day. Per interview on 06/27/22 at 3:50 PM Patient #1 stated the Buspirone HCL was taken three times per day. Per interview on 06/28/22 at 3:00 PM Staff D confirmed these 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 on record review, policy review, and staff interview, the agency failed to ensure all visits contained a frequency and duration for two of seven records reviewed (Patient #2 and #3). The census was 38. Findings include: Review of agency policy titled, "Acceptance of Patients, plan of care and medical supervision," revised 05/2012, revealed the plan of care in consultation with the agency staff covers all pertinent diagnosis...frequency and duration of visits. 1. Review of medical record for Patient #2 revealed a physician ordered plan of care dated 04/30/22 with orders for the home health aide (HHA) to visit 28 hours per week. There was no frequency of visits per week or how long the HHA's visits were to be. 2. Review of medical record for Patient #3 revealed a physician ordered plan of care dated 05/06/22 with orders for the HHA to visit 52 hours per week. There was no frequency of visits per week or how long the HHA's visits were to be. Per interview on 06/28/22 at 3:38 PM Staff F confirmed there was no frequency or duration of visits included on the plans of care.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on staff vaccination information review, policy review and staff interview, the agency failed to develop policies and procedures to ensure that all staff are fully vaccinated for COVID-19. The agency vaccination rate was 100%. This could all patients receiving services from this agency. The census was 38. Findings include: Review of the policy and procedure manual did not reveal a policy to ensure all staff are fully vaccinate for COVID-19. Review of staff vaccination records revealed the agency had a 100% vaccination rate. Per interview on 06/27/22 at 12:50 PM Staff F confirmed the lack of a vaccine policy.