Every finding on record at Horizon Home Health Care, Inc

Recertification survey completed. Standard level deficiencies cited.

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), §485.625(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, "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: A. Based on a review of the Agency’s Emergency Preparedness Plan and staff interview, it was determined the Agency failed to provide training of the Emergency Preparedness Plan. This has the potential to affect all patients served. Findings include: 1. The Agency's Emergency Preparedness binder was reviewed on 10/05/2022 at 11:30 AM. The binder lacked documentation on training of the Emergency Preparedness Plan. 2. During an interview with the Administrator and Director of Nursing on 10/06/2022 at 11:00 AM, the above findings were confirmed. The Director of Nursing and Administrator stated there has been no training of the Emergency Preparedness Plan since 2019.

Recertification survey completed. Standard level deficiencies cited. Abbreviations: Pt.= Patient Pts.= Patients SOC= Start of Care DOH= Date of Hire COVID-19= Coronavirus Disease 2019

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: A. Based on clinical records review, policy review, and staff interview, it was determined the Agency failed to ensure informed consents included the disciplines and frequency of services provided prior to the start of care. This was found in 4 of 7 (pts. #6, 3, 4 and 7) clinical records reviewed. Pt #3 SOC 09/10/2022 Diagnosis: Hypertension. The clinical record of Pt. #3 was reviewed on 10/05/2022 at 3:30 PM. The record contained “Consent and Authorization of Home Services” was signed by Pt. #3 and dated 09/10/2022. The clinical record lacked Pt. #3’s consent to disciplines and frequency of care provided prior to SOC. Pt #4 SOC 09/03/2022 Diagnosis: Hypertension. The clinical record of Pt. #4 was reviewed on 10/04/2022 at 12:00 PM. The record contained “Consent and Authorization of Home Services” was signed by Pt. #4 and dated 09/03/2022. The clinical record lacked Pt. #4’s consent to disciplines and frequency of care provided prior to SOC. Pt #7 SOC 10/26/2021 Diagnosis: Diabetes. The clinical record was reviewed on 10/05/2022 at 9:00 AM. The record contained “Consent and Authorization of Home Services” was signed by Pt. #7 and dated 10/26/2021. The record lacked Pt.#7’s consent to disciplines and frequency of care provided prior to SOC. During interviews with the Administrator and Director of Nursing between 11:00 AM to 12:15 PM, the Director of Nursing confirmed the above findings. . Findings include: 1. Pt. #6 SOC 04/28/2022 Diagnosis: Pressure Ulcer of Right Buttocks, stage 2. The clinical record was reviewed on 10/04/2022 at 2:00 PM. The record included a consent form titled, “Consent of Authorization of Home Services,” signed by Pt. #6 and dated 04/28/2022. The Consent included a section documenting, “…Consent for treatment… c)discipline… d)frequency…). Both section c and d were blank. The clinical record lacked documentation of Pt. # 6’s consent to disciplines and frequency of care provided prior to SOC. 5. A policy titled, “Patient’s Bill of Rights/Responsibilities,” was reviewed on 10/05/2022 at 1:50 PM. The policy documented, “… Patients have the right… To be notified in advance about the care that is to be furnished, they type (disciplines) of the caregivers who will furnish the care and the frequency of the visits that are proposed to be furnished…”

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: A. Based on clinical records review, policy review and staff interview it was determined the Agency failed to administer or arrange for the administration of the influenza and pneumococcal vaccines as per Agency policy. This was found in 4 out of 7 (Pts. #5, 3, 4 and 7) clinical records reviewed. 2. Pt. #3 SOC 09/10/2022 Diagnosis: Hypertension. The clinical record of Pt. #3 was reviewed on 10/05/2022 at 3:30 PM. The clinical record included a document titled, “Flu/Pneumonia Vaccine Questionnaire.” The questionnaire documented Pt. # 3’s interest in receiving both the Influenza vaccination and Pneumonia vaccination. The record lacked documentation of the administration or arrangement outcome. 3. Pt. # 4 SOC 09/03/2022 Diagnosis: Hypertension. The clinical record of Pt. #4 was reviewed on 10/04/2022 at 12:00 PM. The clinical record included a document titled, “Flu/Pneumonia Vaccine Questionnaire.” The questionnaire documented Pt. # 4’s interest in receiving both the Influenza vaccination and Pneumonia vaccination. The record lacked documentation of the administration or arrangement outcome. 4. Pt. # 7 SOC 10/26/2021 Diagnosis: Diabetes. The clinical record was reviewed on 10/05/2022 at 9:00 AM. The clinical record lacked Pt. # 7’s assessment for Influenza and Pneumonia vaccination. 5. The Agency’s undated policy on Influenza Vaccination documented: “For all patients that will be admitted between November 1 to February 28 and existing active patients, the Registered Nurse shall document on the Flu and Pneumonia Vaccine Questionnaire regarding the administration or arrangement for administration to each patient….prior to or upon service initiation, unless the patient refuses…When a referral or arrangement for an Influenza vaccine is made… the nurse case manager shall document…. including: a)date of offer or referral, b) the patient’s response (acceptance or refusal), c) result, d) outcome.” The Agency’s undated policy on Pneumococcal Vaccination documented: “ Upon admission, the Registered Nurse shall complete the “Flu and Pneumonia Vaccine Questionnaire” regarding the administration or arrangement for administration….prior to or upon service initiation, unless the patient refuses…When a referral or arrangement for pneumonia vaccine is made….the nurse case manager shall document….including: a)date of offer or referral, b) the patient’s response (acceptance or refusal), c) result, d) outcome.” 6. During interviews with Administrator on 10/06/2022 between 11:00 AM to 12:15 PM , the Director of Nursing confirmed the above findings. . Findings include: 1. Pt. #5 SOC 08/20/2022 Diagnosis: Hypertensive Heart Disease. The clinical record was reviewed on 10/06/2022 at 12:30 PM. The clinical record included a document titled, “Flu/Pneumonia Vaccine Questionnaire.” The questionnaire documented Pt. # 5’s interest in receiving both the Influenza vaccination and Pneumonia vaccination. The record lacked documentation of the administration or arrangement outcome.

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: A. Based on review of the Agency’s COVID-19 Vaccination records, policy review and staff interview, it was determined the Agency failed to track and securely document clinical contraindications and contingency plans for staff who are not fully vaccinated. This was found in 1 of 1 (Employee # 5) exempt employees providing patient care. . Findings include: 1. Employee #5 (DOH 04/07/2022). COVID-19 vaccination records were reviewed on 10/06/2022 at 10:30 AM. The records included an exemption for Employee #5. The record lacked documentation of a medical exemption signed and dated by a licensed practitioner. 2. An Agency policy titled, “COVID-19 Vaccine Mandate Policy,” was reviewed on 10/06/2022 at 10:45 AM. The policy documented, “…22…Agency will obtain signed and dated documentation from a licensed practitioner…which confirms recognized clinical contraindications to vaccine and which supports staff request for medical exemptions from vaccine… 24… staff who are not fully vaccinated will be required to:… Be tested at least weakly…” 3. During an interview with the Director of Nursing on 10/06/2022 at 3:00 PM, she stated Employee #5 is actively seeing patients. She stated employee #5 sent her one negative COVID-19 test result in August of 2022. 4. During an interview with the Administrator at 3:10 PM, the above findings were confirmed.