Every finding on record at Home Healthcare Solutions Compmay LLC

The Emergency Preparedness requirements were evaluated in conjunction with the recertification survey, on 1/25/24. Standard level deficiencies cited.

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 Agency’s Emergency Preparedness Plan and staff interview, it was determined the Agency failed to ensure the communication plan was complete. This has potential to affect all Pts. receiving services. Findings include: 1. The Agency’s Emergency Preparedness Plan revision date November 2023 was reviewed on 1/25/24. The plan lacked the names and contact information of employees, contracted staff and vendors. 2. During an interview with the Director of Nursing on 1/25/24 from 11:30 AM to 12:40 PM, the Director of Nursing confirmed the Agency failed to ensure the Agency’s Emergency Preparedness communication plan was complete.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of Agency’s Emergency Preparedness Plan, In-services binder and staff interview, it was determined the Agency failed to conduct staff training related to the Emergency Preparedness Plan. Findings include: 1. The Agency’s Emergency Preparedness Plan and In-service binder were reviewed on 1/25/24 at 9:00 AM. The Emergency Preparedness Plan documented: “….Training is conducted for all new employees, volunteers and individuals providing services under arrangement. Annual refresher training is also conducted. Training records are available for review, including the subject matter taught, the date (s), and the names of personnel who attended….” As of 01/25/24, there was no documentation that the Agency conducted staff training in 2021, 2022 and 2023. 2. During an interview with the Director of Nursing on 1/25/24 from 11:30 AM to 12:40 PM, the Director of Nursing confirmed the Agency failed to provide staff training regarding the Emergency Preparedness Disaster Plan.

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 review of Agency’s Emergency Preparedness Plan and Staff interview, it was determined that the Agency failed to ensure testing of the Emergency Preparedness Plan was conducted. Findings include: 1. The Agency’s Emergency Preparedness Plan was reviewed on 1/25/24 at 9:00 AM. The Emergency Plan documented “….Testing: After-Action Reports on exercises and actual event are in filed separately. Dates of exercises are listed below:…..November 2021 Tabletop Exercise….November 2022 Tabletop Exercise….November 2023 Tabletop Exercise….” As of 1/25/24, there was no documentation that the Agency conducted testing in 2021, 2022 and 2023. 2. During an interview with the Director of Nursing on 1/25/24 from 11:30 AM to 12:40 PM, the Director of Nursing confirmed the above findings.

A recertification survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 1/25/23. Standard level deficiencies cited. Abbreviations: SN = Skilled Nurse Pt./Pts. = Patient/Patients W = Week AM = Morning PM = Evening POC= Plan of Care SOC= Start of Care PT= Physical Therapy OT= Occupational Therapy RN= Registered Nurse MSW= Master Social Worker

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on review of the Agency's Pt. admission folder, observation during home visits and staff interview, it was determined the Agency failed to provide the Pt./patient's representative information regarding the Administrator. This was found in 17 of 17 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17) clinical records reviewed. Findings include: 1. The Agency's Pt. admission folder was reviewed on 1/22/24. The folder lacked the Administrator’s name, address, and phone number to file a complaint and/or grievance. 2. On 1/22/24 and 1/23/24, home visits were conducted on the following Pts. Pt. #1. SOC 12/08/23 Pt. #2. SOC 12/30/23 Pt. #3. SOC 11/22/23 Pt. #4. SOC 10/21/23 Pt. #5. SOC 10/25/23 Pt. #6. SOC 12/29/23 Pt. #7. SOC 10/03/23 During the home visits, the patient's admission folder was observed and lacked the name and contact information of the Administrator. 3. The clinical records of the following Pts. were reviewed from 1/22/24 at 11:30 AM to 1/24/24 at 3:00 PM: Pt. #1. SOC 12/08/23 Pt. #2. SOC 12/30/23 Pt. #3. SOC 11/22/23 Pt. #4. SOC 10/21/23 Pt. #5. SOC 10/25/23 Pt. #6. SOC 12/29/23 Pt. #7. SOC 10/03/23 Pt. #8. SOC 09/29/23 Pt. #9. SOC 09/04/23 Pt. #10. SOC 05/16/23 Pt. #11. SOC 12/27/23 Pt. #12. SOC 11/17/23 Pt. #13. SOC 09/15/23 Pt. #14. SOC 04/10/23 Pt. #15. SOC 04/07/23 Pt. #16. SOC 12/27/23 Pt. #17. SOC 03/30/23 The clinical records lacked documentation that the Pt./patient's representative was provided the name and contact of the Administrator to file a complaint or grievance. 4. During an interview with the Director of Nursing (DON) on 1/25/24 at 11:30 AM, the DON confirmed the Agency failed to provide the Pt./patient's representative with the Administrator's name and contact information.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on review of clinical records, observation during home visits, and staff interviews, it was determined that the Agency failed to ensure Pts. were informed in writing of the disciplines to provide care/service, and the frequency of visits provided by each discipline. This was found in 17 of 17 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17) clinical records reviewed. Findings include: 1. The clinical records of the following Pts. were reviewed from 1/22/24 at 11:30 AM to 1/24/24 at 3:00 PM: Pt. #1. SOC 12/08/23. Pt. received SN services. Pt. #2. SOC 12/30/23. Pt. received SN, PT, OT and HHA services. Pt. #3. SOC 11/22/23. Pt. received SN services. Pt. #4. SOC 10/21/23. Pt. received PT services. Pt. #5. SOC 10/25/23. Pt. received SN and PT services. Pt. #6. SOC 12/29/23. Pt. received SN, PT and OT services. Pt. #7. SOC 10/03/23. Pt. received PT and OT services. Pt. #8. SOC 09/09/23. Pt. received SN, PT, OT and MSW services. Pt. #9. SOC 09/04/23. Pt. received SN, OT and HHA services. Pt. #10. SOC 05/16/23. Pt. received SN services. Pt. #11. SOC 12/27/23. Pt. received SN services. Pt. #12. SOC 11/17/23. Pt. received SN, PT and OT services. Pt. #13. SOC 09/15/23. Pt. received OT, SN services. Pt. #14. SOC 04/10/23. Pt received Pt, OT services. Pt. #15. SOC 04/07/23. Pt received SN services. Pt. #16. SOC 12/27/23. Pt. received SN, PT and OT services. Pt. #17. SOC 03/30/23. Pt. received SN, PT, OT and HHA services. The records lacked documentation that the Pt. or legal guardian was notified in writing of the services to be provided and the frequency. 2. The following home visits were conducted from 1/22/24 at 3:00 PM and 1/23/23 from 9:00 AM to 2:45 PM. Pt. #1. SOC 12/08/23 Pt. #2. SOC 12/30/23 Pt. #3. SOC 11/22/23 Pt. #4. SOC 10/21/23 Pt. #5. SOC 10/25/23 Pt. #6. SOC 12/29/23 Pt. #7. SOC 10/03/23 During the home visits, the patient's admission folder was observed and lacked documentation of the services provided, and the frequency of the visits. 3. During an interview with the Director of Nursing (DON) on 1/25/24 at 11:30 AM, the DON confirmed the Agency does not inform Pts. in writing of the frequency of visits and failed to specify all disciplines who provide service.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on clinical records review and staff interview, it was determined the Agency failed to ensure staff provide services, as ordered by the Physician, indicated in the Plan of Care. This was found in 5 of 17 (Pts. #6, 8, 10, 12 and 13) clinical records reviewed. Findings include: 1. Pt. #6 was admitted to Home Health Services on 12/29/23 with diagnosis of Flu due to other identified Influenza virus. The clinical record was reviewed on 1/23/24. The Plan of Care for certification period of 12/29/23 to 2/26/24, required to notify physician of oxygen saturation less than 90% (percent) and to assess oxygen saturation on room air every visit. The Skilled Nurse note dated 1/16/24 lacked an oxygen saturation assessment as ordered in the Plan of care. 2. Pt. # 8 was admitted to Home Health Services on 9/29/23 with diagnosis of Varicose Veins of left lower extremity. The clinical record was reviewed on 1/23/24. The Plan of care for certification period of 11/28/23 to 1/26/24, required to notify physician of oxygen saturation less than 90% (percent). The Skilled Nurse notes dated 12/1/23, 1/1/24, 1/5/24, 1/8/24, 1/12/24 and 1/22/24, lacked an oxygen saturation assessment as ordered in the Plan of care. 3. Pt. #10 was admitted to Home Health Services on 5/16/23 with diagnosis of Venous Insufficiency. The clinical record was reviewed on 1/24/24. The Plan of care for certification period of 11/12/23 to 1/10/24 contained an order for Physical Therapy to evaluate and treat. The record lacked documentation that a Physical Therapy evaluation was done as ordered in the Plan of Care. 4. Pt. #12 was admitted to Home Health Services on 11/17/23 with diagnosis of Alzheimer’s disease. The clinical record was reviewed on 1/24/24. The Plan of care for certification period of 11/17/23 to 1/15/24, required to notify physician of oxygen saturation less than 90% (percent). The Physical Therapy Assistant notes dated 12/14/23 and 12/21/23, lacked an oxygen saturation assessment as ordered in the Plan of care. 5. Pt. #13 was admitted to Home Health Services on 9/15/23 with diagnosis of Other Chronic Pain. The clinical record was reviewed on 1/24/24. The Plan of care for certification period of 11/14/23 to 1/12/24 contained an order for HHA (Home Health Aide) assistance with ADLs (Activities of Daily Living). As of 1/24/24, there is no documentation that Home health aide services were provided, as ordered in the Plan of care. 6. During an interview with the Director of Nursing on 1/24/24 from 11:30 AM to 12:40 PM, the Director of Nursing confirmed the above findings.

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: Based on review of clinical records, and staff interview, it was determined the Agency failed to assess the need for Influenza and Pneumococcal Pneumonia vaccines for 16 of 17 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 16, and 17) clinical records reviewed. Findings include: 1. The following Pts. were admitted for skilled home health and clinical records were reviewed beginning from1/22/24 at 12:00 PM to 1/24/23 at 3:30 PM: Pt. #1. SOC 12/08/23 Pt. #2. SOC 12/30/23 Pt. #3. SOC 11/22/23 Pt. #4. SOC 10/21/23 Pt. #5. SOC 10/25/23 Pt. #6. SOC 12/29/23 Pt. #7. SOC 10/03/23 Pt. #8. SOC 09/09/23 Pt. #9. SOC 09/04/23 Pt. #10. SOC 12/27/23 Pt. #11. SOC 12/27/23 Pt. #13. SOC 09/15/23 Pt. #14. SOC 04/10/23 Pt. #15. SOC 04/07/23 Pt. #16. SOC 12/27/23 Pt. #17. SOC 03/30/23 As of 1/25/24, the clinical records reviewed lacked documentation of Influenza and Pneumococcal Pneumonia inquiry/assessment. 2. During an interview with the Director of Nursing (DON) on 1/25/24 at 11:30 AM, it was stated that during the start of care, the patient’s Influenza and Pneumococcal Pneumonia vaccination status is assessed, and this information is documented in the clinical record. During the same interview, the above finding was confirmed.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, it was determined the Agency failed to ensure Home Health Aides provided services as ordered by a Physician and included in the POC. This was found in 1 of 3 (Pt. #9) clinical records reviewed, wherein Home health aide services were provided. Findings include: 1. Pt #9 was admitted to Home Health Services on 9/4/23 with diagnosis of Pressure Ulcer of Left ankle, stage 2. The clinical record was reviewed on 1/24/24. The Plan of Care for certification period of 1/2/24 to 3/1/24 included Home Health Aide (HHA) frequency of 2 times a week for 9 weeks. The clinical record lacked documentation that HHA services were provided for the week of 1/7/24 to 1/13/24 and the week of 1/14/24 to 1/20/24, as ordered. 2. During an interview with the Director of Nursing on 1/25/24 from 11:30 AM to 12:40 PM, the Director of Nursing 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 review of clinical records and staff interview, it was determined that the Agency failed to ensure the Physician or receiving facility was sent a copy of the Discharge summary within 5 business days of discharge. This was found in 1 of 5 (Pts.# 14) closed clinical records reviewed. Findings include: 1. Pt. #14 was admitted to Home Health Services on 4/10/23 with diagnosis of Acute Exacerbation of Bronchiectasis. The closed clinical record was reviewed on 1/24/24. The record contained the Agency's Discharge Summary completed by the Physical Therapy, indicating patient was discharged on 4/25/23. The record included a transmission report indicating the discharge summary was sent to the physician on 5/22/23, more than 5 days after discharge. 2. During interview with the Director of Nursing on 1/25/24 from 11:30 AM to 12:40 PM, the Director of Nursing stated that Agency was unaware of timeframe for sending discharge summary and confirmed the above findings.

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: Based on clinical records reviews and staff interview, it was determined the Agency failed to ensure that documentation entered into the clinical record was complete. This was found in 16 of 17 (Pts. #1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 15, 16 and 17) clinical records reviewed. Findings include: 1. The following clinical records were reviewed from 1/22/24 to 1/24/24: Pt. #1 Start of Care (SOC) 12/8/23 Pt. #2 SOC 12/30/23 Pt. #3 SOC 11/22/23 Pt.#4 SOC 10/21/23 Pt.#5 SOC 10/25/23 Pt. #6 SOC 12/9/23 Pt. #7 SOC 10/3/23 Pt. #8 SOC 9/29/23 Pt. #9 SOC 9/4/23 Pt. #11 SOC 12/27/23 Pt. #12 SOC 11/17/23 Pt. #13 SOC 9/15/23 Pt. #14 SOC 4/10/23 Pt. #15 SOC 4/7/23 Pt. #16 SOC 12/27/23 Pt. #17 SOC 3/30/23 The form titled: “Beneficiary Elected Transfer”, for Pts. # 2, 3, 4, 5, 6, 7, 8, 11, 12, 13, 14, 15 and 17 signed by the patient/patient’s representative and dated at the Start of Care (SOC), lacked the name of Agency the Patient previously received service. The forms entered into the clinical record were incomplete. The form containing section on Advance Directives, for Pts. #1,7, 9, 11, 14 and 16 provided options for the Patient/ patient’s representative to choose regarding Advance Directives, this section was left blank. The forms entered into the clinical record were incomplete. 2. During interviews with the Director of Nursing on 1/24/24 from 10:30 AM to 12:40 PM, the Director of Nursing confirmed that above findings.